Biofilm-disrupting irrigation in established hip & knee prosthetic joint infection: a scoping review

Biofilm formation on prosthetic joint surfaces is a key mechanism causing treatment failure in prosthetic joint infection, and intraoperative irrigation is routinely used during debridement, antibiotics, and implant retention and revision surgery. Clinical evidence directly supporting biofilm-disrupting irrigation solutions in established PJI is limited and unclear. This scoping review mapped clinical evidence evaluating defined biofilm-disrupting irrigation strategies used during surgery for established hip and knee prosthetic joint infection and identified existing evidence gaps. A scoping review was structured in accordance with PRISMA-ScR guidance. PubMed, Scopus and Embase were searched. Clinical studies in adults undergoing surgery for established PJI that reported clinical outcomes associated with a defined irrigation solution with intended biofilm-disrupting activity beyond normal saline were eligible. Prevention-only arthroplasty studies were charted separately for context. Data were recorded on study design, population, causative organisms, surgical procedure, irrigant protocol, comparators, follow-up, outcome definitions and adverse events. Semi-quantitative descriptive analysis and MINORS risk of bias assessment was undertaken. Four clinical studies met inclusion criteria, all retrospective observational or comparative cohorts. The available evidence primarily involved povidone-iodine & hydrogen peroxide sequences, vancomycin-povidone iodine protocolised irrigation, and Bactisure® based irrigation during debridement, antibiotics and implant retention. Comparative studies reported variable findings: protocolised povidone-iodine/hydrogen peroxide and vancomycin-povidone iodine approaches were associated with lower failure in selected cohorts, whereas Bactisure® did not significantly reduce DAIR failure compared with standard DAIR in the largest comparative cohort. Interpretation is limited by small study numbers, retrospective design, heterogeneous infection timing, organism profiles, host factors, component exchange practices, antimicrobial regimens, and inconsistent outcome definitions. Prevention-only arthroplasty lavage studies were considered contextual evidence only and should not be extrapolated directly to established PJI. Current evidence does not identify a superior irrigant or justify treatment recommendations. Future multicentre prospective trials should evaluate standardised irrigation protocols within standardised treatment bundles, use musculoskeletal infection society definitions, report adverse events and cytotoxicity, and include patient-reported outcomes and cost-effectiveness analysis.