Novel citrate-based wound irrigation system disrupting biofilms and preventing orthopaedic surgery infections: technique guide and systematic review

Introduction

Surgical site infections (SSIs), bacterial biofilm development, and periprosthetic joint infections (PJIs) are significant complications that undermine surgical success and patient recovery in orthopedic surgery (1,2). The increased volume of total joint arthroplasties (TJAs), among the most frequently performed procedures in the United States (U.S.), correlates with a heightened risk of PJIs. Despite a relatively low incidence of PJIs—less than 2%—the consequences of these infections are severe (3). In particular, a diagnosis of chronic PJI has been equated to the morbidities of most cancers, given its significant morbidity to treat and difficulty to eradicate (4). In the context of chronic PJIs, bacterial biofilm formation on implanted devices plays a central role in PJIs, contributing to antibiotic resistance, immune evasion, and recurrent infections. The U.S. financial burden of managing PJIs is projected to reach $1.85 billion annually by 2030, emphasizing the need for more effective preventive strategies (5).

Biofilms pose a unique challenge due to their structural complexity and resistance to conventional treatments (6). Standard irrigation solutions, such as saline or iodine-based products, often fail to effectively disrupt biofilms and can cause cytotoxic effects on surrounding healthy tissues, further complicating recovery (7). These limitations highlight the necessity for innovative solutions that can better address biofilm-associated infections without compromising tissue viability (8,9). A promising approach involves a citrate-based irrigation solution designed to disrupt biofilms by targeting their extracellular matrix (10). This solution leverages citric acid and sodium citrate to chelate metal ions essential for biofilm stability, breaking down its protective structure (11,12). Additionally, the inclusion of sodium lauryl sulfate as a surfactant enhances its ability to remove debris and bacteria from surgical sites while minimizing residual contamination (13). This combination not only disrupts biofilms, but also provides antimicrobial protection with minimal toxicity to native cells, fostering improved wound healing and overall recovery (13).

Compared to other irrigation agents, the citrate-based solution offers significant advantages. It is less toxic than traditional iodine or chlorhexidine solutions, making it safer for use on delicate tissues (14). Its enhanced biofilm-disrupting capabilities and potential to reduce postoperative swelling and improve range of motion (ROM) provide added benefits, leading to faster recovery and better overall outcomes (15). These attributes make it a compelling alternative for infection prevention in both orthopedic and spine surgeries.

This paper reviews the available evidence on this innovative irrigation solution, focusing on studies demonstrating its effectiveness in TJA and characterizing its potential benefits in spine surgeries. Procedures such as multi-level fusions, posterior cervical surgeries, and deformity corrections, which are associated with higher infection rates, stand to benefit significantly from its use, especially in patients with comorbidities like diabetes or smoking. This study also discusses optimal application techniques, timing, and dosage to maximize efficacy. Future research, including randomized trials, will be critical to further validate its safety and establish it as a standard preventative measure across surgical specialties. We present this article in accordance with the PRISMA reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-25-45/rc).

Methods

The irrigation solution utilized in this study is a citrate-based surgical lavage system specifically formulated to target bacterial biofilms and reduce microbial contamination, XPERIENCE^TM Advanced Surgical Irrigation (Next Science LLC, Jacksonville, FL, USA). This solution comprises three primary active components: citric acid (32.5 g/L), sodium citrate (31.3 g/L), and sodium lauryl sulfate (1.00 g/L), dissolved in water. Citric acid serves as a chelating agent to sequester metal ions critical for the structural integrity of bacterial biofilms, thereby destabilizing their extracellular matrix. Sodium citrate functions as a pH buffer to maintain an optimal environment for antimicrobial activity, while sodium lauryl sulfate, a surfactant, aids in the mechanical removal of debris and bacteria by reducing surface tension. There are a variety of methods to use XPERIENCE intra-operatively, including gravity flow, pulse lavage, and continuous irrigation. In general, it is applied throughout a surgical procedure to clean the wound bed before/after any component placement, with no additional rinsing required after application.

The preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines were used to conduct this systematic review. A search of the PubMed-MEDLINE and Cochrane Library databases was searched with a date range from January 1, 2020 to November 1, 2024 to identify all publications since the last review of this topic. The search terms were “XPERIENCE”, “Novel Citrate-Based Irrigation System” and “Orthopaedic Surgery”. Databases were searched, with title and abstract of each article reviewed to determine relevancy. Article inclusion eligibility was determined by reviewing the title and corresponding abstract, with a full-text review performed to screen articles meeting initial eligibility.

Study selection

Studies included in this systematic review were basic science or clinical studies assessing safety/efficacy of citrate-based irrigation. Literature reviews were included, while studies outside of the time period of interest were excluded. The overall selection and review process is summarized in Figure 1. If a consensus could not be reached, the senior author (A.E.R.) made the final decision.

Figure 1 Flow diagram detailing database search.

Data extraction

Studies meeting inclusion criteria were tabulated using Microsoft Excel. Title, author, publication year, journal name, type, and level of evidence (LOE) were included. For comparative clinical studies, sample size, procedure type, and outcomes/conclusions were obtained. Postoperative outcome variables included prosthetic joint infection (PJI) rate, SSI rate, return to operating room (OR), and post-operative ROM.

Quality assessment

Articles were assessed for quality using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Studies included were graded on evidence level using pre-defined standard criteria, with any score differences discussed among reviewers and a consensus established for final scoring. In addition, potential biases were addressed through the Newcastle-Ottawa Scale (NOS), which is comprised of eight questions separated into three categories detailing whether studies were controlled for confounding variables, potential biases from outcome measures and overall external validity of such studies.

Results

General study characteristics

Our initial search yielded 64 studies meeting screening criteria, which underwent full review. Of these, 9 studies met inclusion/exclusion criteria and were included in the analysis. The studies had a mean NOS of 6.7±0.7 (range, 6–8) out of a possible 9 with a mean MINORS of 18.2±1.5 (range, 18–21) out of a possible 24.

XPERIENCE^TM Advanced Surgical Irrigation has a growing number of basic science studies (Table 1). Specifically, it presents a novel approach to preventing SSIs and PJIs by effectively disrupting biofilms by chelating metal ions within the biofilm matrix, reducing microbial loads by up to six logs for planktonic bacteria and four to eight logs for biofilms with maximum effect within 1–2 hours post-application (20). Its composition, including citric acid and sodium lauryl sulfate, demonstrates minimal cytotoxicity to native cells like osteoblasts and fibroblasts, addressing a key limitation of traditional solutions such as povidone-iodine and chlorhexidine (10). Clinical outcomes have shown significant reductions in postoperative swelling, enhanced ROM, and faster opioid weaning timelines among patients undergoing procedures such as total knee arthroplasty (TKA) (20). Additionally, the solution’s no-rinse formulation provides up to 5 hours of antimicrobial protection, differentiating it from conventional options that require rinsing to mitigate cytotoxic effects (19). These findings position XPERIENCE as a transformative tool in surgical infection prevention, with broad applications across orthopedic joint arthroplasty (16).

Apart from basic science studies, there are a growing number of clinical studies that support safety and efficacy of a citrate-based wound irrigation system (Table 2). Specifically, XPERIENCE^TM has been evaluated across multiple studies, with demonstrated effectiveness in reducing SSIs, improving postoperative outcomes, and enhancing overall recovery in orthopedic procedures. In a pilot study by Battista et al., 61 TKA patients were analyzed, with 31 treated using XPERIENCE^TM and 30 with povidone-iodine (20). The XPERIENCE^TM group showed significant reductions in postoperative swelling at day 7 (P<0.05) and day 14 (P<0.01), as well as improved ROM at day 7 (P=0.043) and reduced reliance on ambulatory assistive devices by day 21 (P=0.049). Additionally, opioid use was reduced, with the XPERIENCE^TM group weaning off opioids eight days earlier than the control group. Vatti et al. conducted a retrospective analysis of 1,295 hip and knee arthroplasties, comparing 471 patients treated with XPERIENCE^TM to 824 treated with povidone-iodine (17). While the PJI rate in the XPERIENCE^TM group was 0% compared to 0.49% in the control group, the difference did not reach statistical significance (P=0.3), although a trend toward fewer returns to the OR was observed.

In another study by Williams et al., 423 primary joint arthroplasties (217 knees, 164 hips, and 42 shoulders) were performed using XPERIENCE^TM, with no cases of PJIs or prosthetic shoulder infections (PSIs) reported within 90 days, despite 95% of patients having at least one high-risk factor for infection (18). Similarly, Singer et al. retrospectively reviewed 524 TKA procedures at an ambulatory surgery center and reported a PJI incidence of 0.19% (one case) and one superficial SSI within 30 days, with the PJI attributed to an unrelated respiratory infection (14). These rates were significantly lower than historical infection rates reported for similar procedures. Across these studies, XPERIENCE^TM consistently demonstrated its ability to reduce infection rates, improve functional outcomes, and shorten recovery times, highlighting its value as a robust tool for infection prevention in orthopedic surgeries.

Indications/considerations for use in spine surgery

Biofilm development is a critical concern in both spine surgery and TJA, though the mechanisms and clinical implications can vary (21,22). In spine surgery, biofilms often form on hardware such as rods, screws, and cages, creating a protective matrix that shields bacteria from antibiotics and immune responses. This can lead to persistent infections, impaired fusion, and the need for revision surgery (23). Similarly, in TJA, biofilms commonly develop on prosthetic surfaces, significantly increasing the risk of PJIs and complicating surgical outcomes (24). The incidence of biofilm-associated infections in orthopaedic TJA is relatively well-documented.

However, the risk in other procedures such as spine surgery can be equally severe, particularly in multi-level fusions or procedures with extensive hardware implantation (25). Effective biofilm management is critical in both settings to prevent chronic infections, reduce the need for revision surgeries, and improve overall patient outcomes. Advanced irrigation systems that target biofilms and reduce bacterial loads play an essential role in mitigating these risks. Patients undergoing spine surgery, particularly those at higher risk of infection or wound complications (26), can benefit significantly from advanced surgical irrigation systems with biofilm-disrupting and antimicrobial properties (Table 3). High-risk groups include individuals with diabetes, obesity, or compromised immune systems, previous surgical infections, as well as smokers, alcohol abuse and patients on immunosuppressive medications (27). Those undergoing complex procedures such as multi-level spinal fusions, deformity corrections, or posterior cervical surgeries—which are associated with elevated rates of SSIs—are especially vulnerable (28). For these patients, surgical irrigation systems that effectively target biofilms, reduce microbial contamination, and minimize cytotoxic effects on native tissues are critical. These systems may also aid in reducing postoperative swelling, inflammation, and complications, ultimately supporting faster recovery and improved outcomes. Incorporating such technologies into spine surgeries can help address challenges faced by high-risk patients, enhancing both short-term recovery and long-term outcomes.

Potential limitations

Of note, despite overall advancements in surgical technique and antiseptic technologies, the lack of standardized disinfection protocols remains a significant barrier to reducing perioperative infection rates. Current practices often vary by institution and surgeon preference, leading to inconsistent outcomes. Establishing evidence-based, uniform disinfection procedures—particularly those targeting biofilm-prone areas such as implant interfaces—would allow for a more systematic and reproducible approach to infection prevention. Standardization would also facilitate comparative research, quality improvement efforts, and the broader adoption of novel agents like citrate-based irrigation systems.

While this review highlights promising results using citrate-based irrigation for disrupting biofilms and reducing postoperative infection, it is essential to acknowledge both its benefits and limitations. Biofilms form through a complex process involving bacterial adhesion, extracellular matrix production, and maturation into antibiotic-resistant colonies. These structures are notoriously difficult to eradicate due to their protective matrix and reduced metabolic activity. The included studies demonstrated significant reductions in microbial load and improved postoperative outcomes; however, most clinical data derive from arthroplasty cohorts, with limited direct evidence in spine populations. Moreover, the lack of long-term data and variability in application techniques limit the generalizability of current findings. Further research should aim to validate these results in high-risk spine surgery settings and clarify the durability of biofilm disruption over time.

Technique for application

During a spine surgery procedure, an advanced irrigation solution can be utilized to optimize microbial decontamination and prevent complications associated with biofilm formation along with efficacy against overall non-biofilm bacterial colonization. This solution is a citrate-based formulation consisting of 32.5 grams/liter (g/L) of citric acid, 31.3 g/L of sodium citrate, and 1.00 g/L of sodium lauryl sulfate dissolved in water (29). These components work synergistically to target the development of bacterial biofilms and reduce microbial contamination near surgical sites and prosthetic devices. Citric acid serves as a chelating agent, binding to metal ions that are critical to the structural integrity of the biofilm’s extracellular polymeric matrix. This disruption weakens the biofilm’s protective layer, exposing bacteria to further antimicrobial effects. Sodium citrate acts as a buffer, maintaining an optimal pH environment for antimicrobial activity without causing cytotoxic effects to native cells. Sodium lauryl sulfate, a surfactant, reduces surface tension, enabling the removal of bacterial aggregates and debris while enhancing the penetrative capacity of the solution (18,19).

Of note, evaluation of the individual components of this citrate-based irrigation solution suggests a favorable safety profile when used near neural structures. Citric acid and sodium citrate, which function as chelators and pH buffers, have demonstrated minimal cytotoxicity to native cell types including osteoblasts and fibroblasts in vitro (10,12). Sodium lauryl sulfate, included at 1.00 g/L as a surfactant, has been associated with mucosal irritation at higher concentrations, but at the formulation used in XPERIENCE^TM, has not shown significant cytotoxicity in relevant cellular assays (13). Overall, current evidence supports safe use when applied topically and suctioned appropriately, without direct intradural exposure nor any documented adverse effects in the spine operative procedures it has been applied.

The application of this irrigation solution is methodical and targeted to ensure maximal benefit throughout the procedure (Figure 2). After exposing the surgical site, the solution is initially applied to remove debris, blood, and contaminants, preparing the area for subsequent surgical interventions. During the placement of spinal hardware, such as screws, rods, or interbody cages, the solution is reapplied to cleanse the hardware-tissue interface and prevent the establishment of biofilms on the implant surfaces (Figure 3). Its no-rinse formulation allows antimicrobial agents to remain active on tissues and hardware, providing extended protection against bacterial colonization. Before wound closure, a final thorough irrigation is performed to remove any residual contaminants and biofilm remnants. Of note, any residual solution that remains after being suctioned out continues its antimicrobial activity in the immediate postoperative period, thereby reducing the risk of SSIs and improving patient outcomes. This strategic use of a biofilm-disrupting irrigation system is particularly valuable in complex spine surgeries, where infection risks are elevated due to extensive tissue exposure and hardware placement.

Figure 2 Citrate-based irrigation system in large 50 cc syringe.

Figure 3 Citrate-based irrigation system applied intra-operatively.

Application protocol for citrate-based irrigation solution in spine surgery

The application protocol for this novel citrate-based irrigation solution is detailed below (Table 4).

Conclusions

This systematic review highlights the transformative potential of a novel citrate-based irrigation solution in preventing infections in both orthopedic and spine surgeries. By effectively disrupting biofilms, reducing microbial loads, and minimizing cytotoxicity, this solution addresses critical limitations of traditional irrigation agents. The evidence supports its efficacy in joint arthroplasty for reducing infection rates, improving postoperative outcomes, and enhancing recovery. Furthermore, its application in spine surgery is particularly promising for high-risk procedures, such as multi-level fusions and deformity corrections, where biofilm formation on hardware poses significant challenges. Tailored application protocols, including pre-implantation cleansing and a no-rinse approach, underscore its practical utility in mitigating infection risks and optimizing surgical outcomes. Future randomized controlled trials are essential to validate these findings, refine application techniques, and establish this innovative solution as a standard component of surgical infection prevention strategies across specialties. By integrating this advanced approach, surgeons can achieve better patient outcomes, reduce healthcare burdens, and set a new benchmark for infection prevention in complex surgical contexts.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Spine Surgery, for the series “Cost, Healthcare Utilization, Patient-Reported Outcomes and Technology in Modern Spine Surgery”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-25-45/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-45/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-25-45/coif). The series “Cost, Healthcare Utilization, Patient-Reported Outcomes and Technology in Modern Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. A.E. served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Journal of Spine Surgery from September 2024 to August 2026. M.K.N. reports consulting fees from Johnson and Johnson MedTech, Pacira Biosciences Inc., Alafair Biosciences, Next Science LLC, Bonutti Technologies, CurvaFix Inc., and Ferghana Partners. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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