Orthopedic surgical site infections (SSIs) represent a formidable challenge across diverse health care settings, but their impact is most profound in resource-limited environments where systemic constraints exacerbate both incidence and outcomes. SSIs are defined as infections occurring within 30 days of a surgical procedure or within one year if a prosthetic implant is placed, and they rank among the most frequent causes of healthcare-associated infections globally [1,2]. Orthopedic procedures, by virtue of extensive tissue dissection, hardware implantation, and frequent emergency presentations such as open fractures, are particularly susceptible to microbial contamination and subsequent infection [3,4].

In high-income countries, the integration of evidence-based infection prevention protocols—including preoperative skin antisepsis with chlorhexidine, perioperative antibiotic prophylaxis, meticulous surgical technique, and postoperative wound care—has reduced SSI incidence in elective orthopedic procedures to below 2% [5]. However, these successes have not been uniformly replicated in low- and middle-income countries (LMICs), where the burden remains alarmingly high. Reports from sub-Saharan Africa, South Asia, and parts of Latin America document SSI prevalence ranging from 10% to 30%, especially following fracture fixation and arthroplasty [6–9]. These figures not only reflect the biological complexity of infection but also highlight a structural inequity in access to safe surgical care.

The consequences of orthopedic SSIs extend far beyond the immediate wound infection. They are associated with prolonged hospital admissions, repeated surgeries, removal of implants, delayed fracture healing, permanent disability, and in severe cases, life-threatening sepsis [10]. For patients in LMICs, who often lack health insurance and rely on out-of-pocket expenditures, the financial repercussions can be catastrophic [11]. From a health system perspective, SSIs drain already scarce resources, consume antibiotics, and contribute to the growing crisis of antimicrobial resistance [12].

Compounding these challenges, the microbiology of SSIs in LMICs shows high prevalence of multidrug-resistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase (ESBL)–producing Escherichia coli, and Pseudomonas aeruginosa [13,14]. These pathogens not only complicate empirical treatment but also limit the effectiveness of standard prophylactic regimens. Furthermore, infrastructural barriers such as intermittent sterilization equipment, inadequate operating theatre ventilation, and limited surgical supplies compromise infection control measures [15].

Nonetheless, substantial evidence supports the effectiveness of simple, low-cost interventions. Timely administration of prophylactic antibiotics, improved hand hygiene, maintenance of normothermia, and standardized surgical safety checklists have demonstrated significant reductions in SSI rates [16–18]. However, the implementation and sustainability of these measures in resource-limited settings remain inconsistent, often due to gaps in policy prioritization, training, and funding [19].

Despite the scale of this problem, there has been no comprehensive meta-analysis synthesizing the prevalence of orthopedic SSIs across LMICs and quantifying the impact of infection prevention strategies. Such evidence is essential to inform national guidelines, direct resource allocation, and identify research and implementation gaps. Therefore, this systematic review and meta-analysis were undertaken to estimate the pooled burden of orthopedic SSIs in resource-constrained environments and to critically appraise the effectiveness of preventive interventions. By consolidating this knowledge, the study aspires to support stakeholders in strengthening surgical safety, reducing avoidable morbidity, and promoting health equity.

Study Design

This systematic review and meta-analysis were designed and conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure methodological transparency and rigor [20]. The review protocol was developed in advance and registered in the PROSPERO international prospective register of systematic reviews to promote accountability and reduce the risk of bias.

Eligibility Criteria

We established clear inclusion and exclusion criteria to identify studies relevant to the objectives of this meta-analysis. Eligible studies were original peer-reviewed articles reporting the prevalence of orthopedic SSIs in LMICs, as classified by the World Bank, or assessing the effectiveness of preventive interventions designed to reduce the incidence of SSIs. Both observational studies—including cross-sectional, cohort, and case-control designs—and RCTs were eligible for inclusion. We included studies that enrolled patients undergoing any type of orthopedic procedure, including fracture fixation, arthroplasty, and elective reconstructive surgeries. Only studies published in English between January 1, 2000, and December 31, 2024, were considered. Studies were excluded if they were case reports, editorials, letters, conference abstracts without sufficient data, or if they exclusively reported superficial wound infections without specifying SSIs according to standardized definitions. Additionally, studies conducted in high-income countries or involving non-orthopedic procedures were excluded to maintain focus on the targeted population and settings.

Information Sources

A comprehensive search was conducted across four major electronic databases: PubMed, Embase, Scopus, and the Cochrane Library. These databases were selected due to their extensive coverage of biomedical and surgical literature. The search encompassed all articles published up to December 31, 2024, to ensure that the review captured the most recent evidence available in this field.

Search Strategy

The search strategy combined both controlled vocabulary terms (MeSH headings) and free-text keywords to maximize sensitivity and specificity. For example, in PubMed, the search string was structured as follows: ("Orthopedic Surgery"[Mesh] OR "Orthopedic Procedures" OR "Bone Surgery" OR "Fracture Fixation") AND ("Surgical Wound Infection"[Mesh] OR "surgical site infection" OR "SSI") AND ("Developing Countries"[Mesh] OR "Low-Income Countries" OR "Resource-Limited Settings" OR "LMIC"). Equivalent search strategies were tailored for the syntax requirements of Embase, Scopus, and Cochrane Library. To enhance the retrieval of potentially eligible studies, the reference lists of all included articles and relevant systematic reviews were manually screened.

Study Selection

Following the removal of duplicate records, titles and abstracts were independently screened by two reviewers against the eligibility criteria. Full-text articles were retrieved for all potentially relevant citations. The same two reviewers independently assessed each full-text article to confirm inclusion. Discrepancies were resolved by discussion, and in cases where consensus could not be reached, a third reviewer adjudicated the decision. The process was documented in detail to ensure reproducibility.

Data Extraction

Data were extracted independently by two reviewers using a pretested, standardized data collection form. The extracted variables included the following: study identifiers (first author, year of publication, country), study design, total sample size, patient demographics, type of orthopedic procedures performed, definitions and diagnostic criteria used for SSIs, microbiological findings (including the prevalence of multidrug-resistant organisms), and details of preventive interventions such as perioperative antibiotic prophylaxis, sterile technique measures, or wound care protocols. For each study, outcomes were recorded as prevalence estimates and, where applicable, relative risks (RRs) or odds ratios (ORs) for intervention effects. When necessary, corresponding authors were contacted for clarification or provision of additional data.

Quality Assessment

The methodological quality of observational studies was assessed using the Newcastle–Ottawa Scale (NOS), which evaluates studies across three domains: selection of participants, comparability of groups, and ascertainment of outcomes [21]. Each study was assigned a score reflecting its risk of bias, classified as low, moderate, or high. For randomized controlled trials, the Cochrane Risk of Bias Tool was applied, which examines key elements including random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, completeness of outcome data, and selective outcome reporting [22]. All quality assessments were conducted independently by two reviewers, with discrepancies resolved through discussion or arbitration by a third reviewer.

Data Synthesis and Statistical Analysis

The primary outcome was the pooled prevalence of orthopedic SSIs across included studies. Secondary outcomes included the pooled effectiveness of preventive interventions, expressed as relative risks with 95% confidence intervals. A random-effects meta-analysis was conducted to account for anticipated heterogeneity resulting from variations in patient populations, surgical settings, and intervention protocols [23]. Statistical heterogeneity was assessed using the I² statistic, with thresholds for interpretation as follows: low (≤25%), moderate (26–50%), substantial (51–75%), and considerable (>75%). Subgroup analyses were planned a priori to explore heterogeneity by procedure type (trauma versus elective), hospital setting (tertiary versus district), and geographical region. Sensitivity analyses were conducted to evaluate the robustness of findings by excluding studies assessed as high risk of bias. Publication bias was assessed visually by funnel plots and statistically using Egger’s regression test. All analyses were performed using Review Manager (RevMan) version 5.4 (Cochrane Collaboration) and STATA version 17 (StataCorp).

Ethics and Dissemination

Because this study involved secondary analysis of published data and did not involve human participants directly, ethical approval was not required. The results will be disseminated through publication in a peer-reviewed journal and presentations at relevant surgical and infection control conferences to inform practice and policy in LMIC settings.

PRISMA Flow Diagram Description

The study selection process is summarized as follows: a total of 2,850 records were identified through database searching. After removing duplicates, 2,300 unique records were screened based on titles and abstracts, of which 2,060 were excluded as irrelevant. The full texts of 240 articles were assessed for eligibility, resulting in the exclusion of 197 studies due to reasons such as lack of SSI prevalence data (n=85), non-orthopedic procedures (n=52), studies conducted in high-income countries (n=40), and inadequate outcome definitions (n=20). Ultimately, 43 studies were included in the qualitative synthesis and meta-analysis (Figure 1).

Figure 1: PRISMA Flow Diagram – Orthopedic Surgical Site Infections Meta-Analysis

RESULTS:

Study Selection

A total of 2,850 records were retrieved through database searches. After removing duplicates, 2,300 unique records were screened by title and abstract. Of these, 2,060 were excluded for irrelevance. The full text of 240 articles was assessed in detail. After excluding 197 studies for reasons such as lack of prevalence data (n=85), non-orthopedic procedures (n=52), studies conducted in high-income countries (n=40), and inadequate outcome definitions (n=20), 43 studies were included in the qualitative synthesis and meta-analysis. The study selection process is depicted in the PRISMA flow diagram.

Characteristics of Included Studies

This met analysis study included 43 studies conducted across a range of low- and middle-income countries, encompassing a cumulative sample of 13,430 orthopedic procedures. The majority of studies originated from India (12 studies), Nigeria (8 studies), and East African nations such as Uganda, Tanzania, and Malawi. Smaller contributions came from countries including Pakistan, Nepal, Bangladesh, Ghana, Zimbabwe, South Africa, and Zambia.

Regarding study design, 26 studies (60%) were cross-sectional, 13 (30%) were prospective cohorts, and 4 (9%) were randomized controlled trials (RCTs) assessing intervention efficacy. Sample sizes ranged from 200 to 600 participants per study, with most studies enrolling between 250 and 400 patients.

Procedures included in the analysis were diverse: fracture fixation was the most commonly studied procedure type, accounting for 21 studies, followed by elective orthopedic surgeries (12 studies), mixed orthopedic procedures (8 studies), and trauma surgeries (4 studies). Among elective surgeries, hip arthroplasty and elective arthroplasty were the most frequently reported.

Definitions of surgical site infection (SSI) varied across studies. The Centers for Disease Control and Prevention (CDC) criteria from 1999 or 2017 were used in 28 studies, the World Health Organization (WHO) criteria in 6 studies, and clinical or combined clinical–microbiological diagnoses in 9 studies (Table 1).

Overall, this dataset represents a broad spectrum of orthopedic practice in resource-limited settings, capturing both emergency and elective procedures, and highlighting the variability in SSI diagnostic criteria and study methodology.

Table 1: Characteristics of Included Studies (n = 43)

Distribution of Included Studies by Study Design and Region

The distribution of the 43 included studies according to geographic region and study design. The largest proportion of studies were conducted in Africa, comprising 18 studies in total, of which 12 were cross-sectional and 6 were prospective cohort studies. Notably, there were no randomized controlled trials reported from African countries.

South Asia contributed 17 studies overall, including 9 cross-sectional studies, 4 prospective cohort studies, and all 4 of the randomized controlled trials included in this review. This reflects relatively greater research activity in intervention evaluation within South Asian settings compared to other regions.

Southeast Asia was represented by 3 studies, consisting of 2 cross-sectional and 1 prospective cohort design, while no randomized trials were identified from this region.

The category of other low- and middle-income countries contributed 5 studies in total, with 3 cross-sectional and 2 prospective cohort studies.

Overall, cross-sectional designs were the most common across all regions, accounting for 26 out of 43 studies. Prospective cohort studies were also frequent, with 13 studies identified. Randomized controlled trials were comparatively scarce, comprising only 4 studies, all of which were conducted in South Asia (Table 2).

This distribution highlights a predominance of observational research methods in the evaluation of surgical site infection prevalence and prevention, particularly in African settings, and indicates that high-quality interventional studies are still limited in many low- and middle-income countries.

Table 2: Distribution of Included Studies by Study Design and Region

Pooled SSI Prevalence by Procedure Type

The pooled prevalence estimates of SSI according to the type of orthopedic procedure studied. Fracture fixation procedures were the most frequently reported, comprising 21 studies. The pooled SSI prevalence for fracture fixation was 16.4%, with a 95% confidence interval ranging from 13.0% to 20.1%. This indicates that infections were relatively common following trauma-related or fracture surgeries in the settings assessed. Elective arthroplasty procedures, such as hip or knee replacements, were evaluated in 9 studies. These procedures demonstrated a lower pooled SSI prevalence of 6.8%, with the 95% confidence interval between 4.3% and 9.8%. This suggests that infection rates were generally lower in planned, elective surgeries compared to emergency or trauma cases.

Mixed orthopedic procedures, which included studies combining various surgical types, were reported in 13 studies. The pooled SSI prevalence in this group was 11.5%, with a 95% confidence interval of 8.0% to 15.2%. This intermediate prevalence likely reflects the inclusion of both elective and emergency cases. Overall, the data indicate that fracture fixation procedures in resource-limited settings are associated with the highest infection risk, while elective arthroplasty has comparatively lower infection rates (Table 3).

Table 3: Pooled SSI Prevalence by Procedure Type

The prevalence of surgical site infections across individual trauma-related studies and the pooled trauma subgroup estimate. Four columns are presented side by side. The first three columns represent individual studies reporting infection prevalence in fracture fixation and trauma surgeries. Specifically, the first study reported a prevalence of 16%, the second study reported the highest prevalence at 20%, and the third study reported a prevalence of 15%. The fourth column depicts the pooled estimate for trauma procedures derived from the meta-analysis, showing an overall prevalence of 16.4%.

Visually, the chart highlights that all three individual studies reported relatively high SSI prevalence, generally exceeding 15%, and that the pooled prevalence closely aligns with these individual values, underscoring the consistent burden of infection associated with orthopedic trauma surgeries in resource-limited settings (Figure 2).

Figure 2: Prevalence of surgical site infections reported in selected studies focusing on trauma-related orthopedic procedures, along with the pooled prevalence estimate

The prevalence of surgical site infections specifically associated with elective arthroplasty procedures. Four columns are shown to illustrate individual study estimates as well as the pooled prevalence for this procedure type. The first column shows the prevalence reported by Kamat et al., with an infection rate of 8%. The second column indicates the lowest observed prevalence among included studies, recorded at 5%. The third column represents another individual study with a prevalence of 7%. The fourth column displays the pooled prevalence estimate for elective arthroplasty procedures derived from the meta-analysis, calculated as 6.8%. The figure highlights that infection rates in elective arthroplasty were consistently lower compared to trauma-related procedures, generally falling below 10% across studies, reflecting a lower but still relevant burden of infection in planned orthopedic surgeries conducted in resource-limited settings (Figure 3).

Figure 3: Prevalence of surgical site infections reported in individual studies evaluating elective arthroplasty procedures, along with the pooled prevalence estimate

The prevalence values range from 8% to 20%. The lowest SSI prevalence was observed at 8%, while the highest reached 20%. Several studies reported intermediate prevalence levels, including 12%, 14%, 15%, and 18%. At the bottom of the figure, the pooled prevalence derived from the meta-analysis is displayed as 12.3%. This value represents the overall estimated infection burden across all studies and procedure types included in the review. The figure 4 demonstrates considerable variability in reported SSI rates between studies but consistently indicates a substantial infection burden in orthopedic surgeries performed in resource-limited settings.

Figure 4: The prevalence of surgical site infections reported in individual studies included in the meta-analysis, along with the pooled prevalence estimate. Individual studies reported SSI rates ranging from 8% to 20%. The pooled prevalence across all studies was 12.3%, underscoring the significant burden of infection in orthopedic procedures conducted in low- and middle-income countries.

Figure 5, funnel plot illustrates the distribution of studies reporting the prevalence of surgical site infections, with each point representing an individual study plotted according to its standard error and log-transformed prevalence estimate. The vertical axis denotes the standard error, spanning from 0.0, which corresponds to more precise estimates derived from larger studies, up to approximately 0.5, indicative of less precise estimates typically observed in smaller studies. The majority of studies are concentrated within a standard error range of 0.1 to 0.3, reflecting a generally acceptable degree of precision across the dataset. The funnel-shaped area delineates the region encompassed by the 95% confidence intervals, within which studies would be expected to cluster in the absence of publication bias (Figure 6). While the distribution appears largely symmetrical, there is a subtle overrepresentation of smaller studies positioned to the left of the pooled estimate, suggesting the possibility of small-study effects or selective reporting. Although most studies lie within the expected confidence boundaries, this slight asymmetry underscores the necessity for cautious interpretation of the aggregated prevalence estimates and consideration of potential bias when drawing conclusions from the pooled data.

 Figure 5: Funnel plot displaying the distribution of studies reporting the prevalence of surgical site infections, plotted as standard error against log-transformed prevalence. Each step/dot represents an individual study included in the meta-analysis. The funnel-shaped region corresponds to the 95% confidence intervals, within which studies are expected to cluster in the absence of publication bias. While most studies fall within this area, a slight asymmetry is evident, suggesting potential small-study effects or selective reporting that may influence the pooled prevalence estimate.

Figure 6: Plot for Prevalence Studies- mild asymmetry suggesting possible publication bias (Egger’s test p=0.04)

The microbiological profile of pathogens identified in surgical site infections following orthopedic procedures in the included studies. Staphylococcus aureus was the most frequently isolated organism, accounting for a mean proportion of 56% of all infections. Notably, methicillin-resistant Staphylococcus aureus (MRSA) represented 40% of these isolates, underscoring the significant presence of multidrug-resistant strains in resource-limited settings. Gram-negative bacilli, including Escherichia coli and Pseudomonas species, comprised 28% of isolates, reflecting the importance of broad-spectrum antimicrobial coverage in empirical treatment. Streptococcus species were identified less frequently, constituting 10% of the infections reported. Anaerobes and other less common organisms accounted for the remaining 6% of isolates (Table 4). This distribution highlights the predominance of Staphylococcus aureus and Gram-negative bacteria as major causative agents of orthopedic surgical site infections and illustrates the need for targeted infection control measures and antimicrobial stewardship to address these pathogens effectively.

Table 4: Pathogen Distribution in SSIs (n=30 studies)

Preventive Interventions

The effectiveness of different infection prevention interventions implemented across the included studies. Three types of interventions were evaluated: standardized infection bundles, preoperative antibiotic prophylaxis, and intraoperative sterile draping protocols. Standardized infection bundles were assessed in ten studies and demonstrated the most substantial reduction in surgical site infection risk, with a pooled relative risk of 0.58 and a 95% confidence interval ranging from 0.44 to 0.75. This association was statistically significant, with a p-value of less than 0.001, indicating a 42% relative risk reduction compared to controls.

Preoperative antibiotic prophylaxis was evaluated in seven studies. This intervention was associated with a pooled relative risk of 0.65 (95% CI: 0.50–0.84) and a p-value of 0.002, reflecting a significant protective effect and a relative reduction in infection risk of approximately 35%. Intraoperative sterile draping protocols were investigated in five studies. These measures produced a pooled relative risk of 0.72 (95% CI: 0.59–0.88) with a p-value of 0.005, demonstrating a statistically significant reduction in SSI risk, though the effect size was somewhat smaller compared to the other interventions (Table 5; Figure 7).

Collectively, these findings highlight that all three interventions were effective in lowering the incidence of orthopedic surgical site infections, with standardized infection bundles showing the greatest overall impact.

Table 5: Effectiveness of Preventive Interventions

Figure 7: Forest Plot of Effectiveness of Infection Prevention Interventions

Comparison of SSI Prevalence Across Subgroups

Trauma procedures, which included fracture fixation and other emergency surgeries, had the highest pooled prevalence of infections at 16.4%, with a 95% confidence interval ranging from 13.0% to 20.1%. The heterogeneity among these studies was substantial, reflected by an I² value of 78%.

Elective procedures demonstrated a considerably lower pooled infection prevalence of 6.8% (95% CI: 4.3%–9.8%), although moderate heterogeneity remained across studies (I² = 65%).

When comparing hospital practices, facilities with established infection prevention protocols reported a pooled SSI prevalence of 8.4% (95% CI: 6.0%–11.2%) and substantial heterogeneity (I² = 70%).

In contrast, hospitals without formal infection control protocols exhibited the highest infection rates overall, with a pooled prevalence of 17.9% (95% CI: 13.2%–22.9%) and considerable heterogeneity (I² = 82%) (Table 6).

These findings indicate that trauma surgeries and inadequate infection control practices are associated with substantially higher SSI rates, highlighting the importance of both procedure type and institutional protocols in determining infection risk.

Table 6: Subgroup Prevalence Estimates

Effectiveness of Infection Prevention Interventions

The use of a standardized infection prevention bundle, which typically combined multiple measures such as perioperative antibiotics, skin antisepsis, and sterile technique checklists, was associated with the greatest reduction in surgical site infection risk. This intervention had a pooled relative risk of 0.58, with a 95% confidence interval from 0.44 to 0.75, and was highly statistically significant (p < 0.001), indicating a 42% relative reduction in infection risk compared to standard care.

Preoperative antibiotic prophylaxis alone demonstrated a pooled relative risk of 0.65 (95% CI: 0.50–0.84) with a p-value of 0.002, reflecting a significant protective effect corresponding to a 35% reduction in SSI risk.

Intraoperative sterile draping protocols, which involved enhanced barrier techniques to maintain asepsis during surgery, were also effective, with a pooled relative risk of 0.72 (95% CI: 0.59–0.88) and a p-value of 0.005, indicating a 28% relative risk reduction (Table 7).

Overall, all three interventions were shown to significantly lower the incidence of surgical site infections in orthopedic procedures, with the standardized infection bundle providing the most substantial benefit.

Table 7: Effectiveness of Interventions

This systematic review and meta-analysis provide a comprehensive assessment of the burden and prevention of orthopedic SSIs in low- and middle-income countries. The findings confirm that SSI prevalence in these settings is substantially higher than in high-income contexts, where rates typically remain below 2% following elective procedures [1]. The pooled prevalence of 12.3% across all included studies underscores the persistent gap in infection control capacity in resource-constrained environments. This disparity reflects multiple factors, including delayed presentation after injury, limited perioperative infrastructure, overcrowded surgical wards, and inconsistent implementation of preventive measures [2,3].

The higher infection rates observed in trauma surgeries (16.4%) relative to elective arthroplasty (6.8%) align with prior reports indicating that emergency procedures and contaminated wounds are principal contributors to elevated SSI risk [4]. Fracture fixation procedures in particular often involve open wounds, prolonged operative times, and hardware implantation under suboptimal sterile conditions, which collectively facilitate microbial contamination and biofilm formation [5]. These observations highlight an urgent need to strengthen perioperative infection prevention for trauma cases, including improvements in debridement protocols, antibiotic timing, and sterile technique adherence.

The microbiological profile observed in this review corroborates existing evidence that Staphylococcus aureus remains the predominant pathogen in orthopedic SSIs, accounting for over half of all infections [6]. The notable proportion of MRSA further complicates empirical antibiotic strategies and underscores the necessity of antimicrobial stewardship programs in LMICs. The relatively high prevalence of Gram-negative bacilli such as Escherichia coli and Pseudomonas spp. reflects environmental contamination and lapses in intraoperative sterility [7,8]. This finding emphasizes the importance of enhanced cleaning protocols, sterilization monitoring, and appropriate antibiotic prophylaxis tailored to local resistance patterns [9].

Encouragingly, this meta-analysis also demonstrates that low-cost, evidence-based interventions can significantly reduce infection risk. Standardized infection prevention bundles, comprising measures such as perioperative antibiotics, skin antisepsis, and sterile draping, were associated with a 42% reduction in SSI risk (RR 0.58). These findings mirror earlier meta-analyses demonstrating the efficacy of bundled interventions in reducing infection rates across surgical disciplines [10]. Preoperative antibiotic prophylaxis alone conferred a 35% reduction in risk, confirming its critical role in SSI prevention [11]. Although intraoperative sterile draping demonstrated a more modest protective effect (RR 0.72), its consistent benefit highlights the importance of barrier precautions even in resource-limited theatres.

However, the significant heterogeneity across studies (I² values ranging from 65% to 82%) indicates considerable variability in study quality, local practices, and patient populations. While subgroup analysis suggests that facilities lacking formal infection protocols experienced nearly double the infection rates (17.9%) compared to those with established protocols (8.4%), causality cannot be definitively inferred. These findings nonetheless reinforce the imperative of institutional commitment to infection control training, supply chain strengthening, and continuous quality improvement.

Publication bias was also detected, as evidenced by the mild asymmetry in the funnel plot and Egger’s test results (p=0.04). This bias likely reflects underreporting of negative or null findings and highlights the need for more rigorous prospective studies and transparent reporting practices in LMIC contexts.

The limitations of this review should be acknowledged. Most included studies were observational, introducing potential confounding and selection bias. Variations in SSI definitions, microbiological sampling, and follow-up duration further complicate direct comparison. Additionally, the inclusion of studies published only in English may have excluded relevant data. Nonetheless, the large cumulative sample size, broad geographical coverage, and consistent trends strengthen the reliability of the findings.

In conclusion, this meta-analysis demonstrates that orthopedic SSIs remain a frequent and preventable cause of postoperative morbidity in low- and middle-income countries. Adoption of standardized infection prevention bundles, perioperative antibiotic prophylaxis, and improved sterile practices can markedly reduce infection rates. Scaling up these measures requires multisectoral collaboration, resource mobilization, and sustained investment in health systems strengthening. Future research should focus on pragmatic trials assessing implementation strategies, cost-effectiveness evaluations, and local adaptation of guidelines to maximize impact and promote surgical safety.

Limitations

This meta-analysis has several limitations that should be considered when interpreting the findings. First, the majority of included studies were observational in design, introducing inherent risks of selection bias, confounding, and heterogeneity in patient populations. Second, definitions of surgical site infection varied across studies, with some relying solely on clinical assessment while others employed microbiological confirmation, potentially leading to misclassification and inconsistent reporting. Third, significant heterogeneity was observed in pooled estimates, reflecting differences in study design, surgical practices, and infection control measures across diverse settings. Fourth, the analysis included only studies published in English, which may have resulted in language bias and the exclusion of relevant research from non-English sources. Finally, the presence of mild funnel plot asymmetry and Egger’s test results suggests potential publication bias, particularly underreporting of studies with lower infection rates or null findings. Collectively, these limitations underscore the need for cautious interpretation and highlight the importance of high-quality prospective studies to validate and extend these observations.

This systematic review and meta-analysis demonstrate that surgical site infections remain a prevalent and significant challenge in orthopedic surgery performed in low- and middle-income countries. The pooled prevalence of SSIs was substantially higher than reported in high-income settings, particularly following trauma-related procedures. The findings reinforce the critical role of standardized infection prevention strategies, including perioperative antibiotic prophylaxis, adherence to sterile technique, and bundled care protocols, which were consistently associated with reduced infection risk. Strengthening infection control practices, improving infrastructure, and fostering antimicrobial stewardship are essential priorities for reducing the burden of SSI in resource-limited environments. Future research should focus on pragmatic trials evaluating implementation strategies, cost-effectiveness, and context-specific adaptations to optimize infection prevention and improve patient outcomes.

Conflict of Interest

The authors declare that they have no conflicts of interest relevant to this study.

Funding Sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements
The authors wish to thank all researchers whose work contributed data to this meta-analysis. We also acknowledge the support of colleagues and institutional staff who facilitated access to reference materials and provided constructive feedback during the preparation of the manuscript.

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