Novel citrate-based wound irrigation system disrupting biofilms and preventing orthopaedic surgery infections:...

Surgical site infections (SSIs), biofilm formation, and periprosthetic joint infections (PJIs) are critical complications in orthopaedic surgery, impacting patient outcomes and increasing healthcare costs. While evidence supports the efficacy of a novel citrate-based irrigation solution in joint arthroplasty, its applications in spine surgery remain underexplored. This study aims to evaluate literature supporting its role in infection prevention for joint arthroplasty, and explores potential indications, benefits, and application techniques for spine surgery.

A systematic review was conducted following preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, searching PubMed-MEDLINE and Cochrane Library databases (January 1, 2020 to November 1, 2024). Studies on the safety/efficacy of citrate-based irrigation solutions were included, focusing on infection rates, biofilm disruption, and recovery outcomes. Quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) and Newcastle-Ottawa Scale. Out of 64 studies screened, nine met inclusion criteria.

The reviewed studies demonstrated that the solution disrupts biofilms by chelating metal ions critical for biofilm stability, reducing microbial loads by up to six logs for planktonic bacteria and four to eight logs for biofilms. Clinical findings in joint arthroplasty included reduced infection rates, reduced swelling, increased range of motion, and faster opioid weaning. Applications for use in spine surgery include multi-level fusions, posterior cervical surgeries, deformity corrections, and procedures in patients with infection risk factors like diabetes or smoking. Techniques include pre-implantation cleansing, periodic irrigation during surgery, and extended antimicrobial protection with a no-rinse protocol to prevent biofilm formation on hardware and tissues.

The citrate-based solution shows promise for infection prevention in orthopedic and spine surgeries, offering biofilm disruption and reduced toxicity. Future randomized trials are necessary to confirm its safety and efficacy, with the potential for broader adoption in surgical protocols.