Optimal protocol for intraoperative irrigation to prevent periprosthetic joint infection - an in vitro study

Sep 29, 2026

Examines how timing and concentration of dilute povidone-iodine irrigation influence bacterial eradication and host-cell cytotoxicity in an in vitro model relevant to periprosthetic joint infection (PJI) prevention. Methicillin-susceptible Staphylococcus aureus was tested on Ti-6Al-4V washers under irrigation patterns applied for 3 minutes within time windows of 15–120 minutes using 0.13% or 0.35% povidone-iodine. Biofilm eradication and biofilm coverage were assessed by culture and microscopy. Cytotoxicity to human osteoblasts and fibroblasts was quantified using WST-1.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages12

Reading Time30 min

AccessFree to download

Aims

Methods

Results

Floating bacteria and biofilm eradication

Biofilm coverage by SEM/fluorescence

Cytotoxicity (osteoblasts and fibroblasts)

Conclusion

Article focus

Key messages

Strengths and limitations

Optimal protocol for intraoperative irrigation to prevent periprosthetic joint infection an in vitro study From Kanazawa University, Kanazawa, Japan Cite this article: Bone Joint Res 2026;15(1): 4–15. DOI: 10. 1302/2046-3758 . 151.BJR-2025-0122.R1 Correspondence should be sent to Tamon Kabata [tamonkabata@yahoo.co.jp](tamonkabata@yahoo.co.jp) T. Kataoka,1 T. Kabata,1 Y. Kajino,2 D. Inoue,1 Y. Yanagi,1 M. Ima,1 M. Tokoro,3 S. Demura1 1Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan 2Orthopaedic Surgery, Kaga Medical Center, Kaga, Japan 3Department of Parasitic Infection Control, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan Aims Many surgeons use dilute povidone-iodine for intraoperative irrigation to prevent periprosthetic joint infection (PJI), with reported effectiveness. However, the timing of irrigation and its optimal concentration for effective bacterial eradication have not been established. This study aimed to investigate how the timing of intraoperative irrigation with dilute povidone-iodine affects bacterial eradication, and to determine the most effective timing and concentration for optimal results in an in vitro model. Methods Ti-6Al-4V washers were placed in medium and prepared methicillin-susceptible Staphylococcus aureus (MSSA) was added. Three different irrigation solutions (saline, 0.13% povidoneiodine, 0.35% povidone-iodine) were applied for three minutes in four different time patterns (15, 30, 60, 120 minutes) and returned to medium. This was repeated until 120 minutes had elapsed. Finally, the washers were exposed to saline and then removed. Floating bacteria in the saline were assessed using a spread plate method, while biofilm bacteria on the washers were evaluated using scanning electron microscopy (SEM), fluorescence microscopy, anda spread plate assay. Cytotoxicity was measured via the WST-1 assay, evaluating humanosteoblast and fibroblast metabolic activity. Results Dilute povidone-iodine irrigation successfully eliminated MSSA from the floating bacteria in all irrigation patterns (floating colony-forming units (CFU)/well: 0 ± 0 at all timepoints for both 0.13% and 0.35%) . For biofilm bacteria, povidone-iodine irrigation within 30 minutes showed the most effective bacterial eradication (mean biofilm CFU/well (SD): 15 mins, 0 (0) vs 0 (0); 30 mins, 1,250 (433) vs 850 (310); 60 mins, 1,812 (429) vs 2,000 (500); 120 mins, 13,200 (2,100) vs 9,800 (1,850) for 0.13% vs 0.35%, respectively) . SEM and fluorescence microscopy revealed low biofilm coverage when the washers were irrigated with povidoneiodine within 30 minutes (mean biofilm coverage,%(SD): 15 mins, 0.145 (0.012) vs 0.123 (0 .010); 30 mins, 0.114 (0 .002) vs 0.124 (0 .006); 60 mins, 7.664 (0 .091) vs 5.405 (0 .351); 120 mins, 18.787 (0.133) vs 18.454 (0.210) for 0.13% vs 0.35%, respectively) . Cytotoxicity analysis indicated that 0.13% povidone-iodine irrigation did not cause significant damage to human osteoblasts after 30, 60, and 120 minutes of exposure (mean cytotoxicity,% cell viability (SD): 15 mins, 45.47 (3.47) vs 23.87 (2.51); 30 mins, 58.24 (3.66) vs 34.93 (0.54); 60 mins, 58.78 (1 .60) vs 46.14 (0 .98); 120 mins, 55.42 (1 .42) vs 43.69 (1 .85) for 0. 13% vs 0.35%, respectively) . Additionally, no significant cytotoxicity was observed in human fibroblasts at any timepoint (mean cytotoxicity,% cell viability (SD): 15 mins, 57.85 (2.91) vs 31.88 (4.67); 30 mins, 56.12 (3 .64) vs 37.78 (3 .54); 60 mins, 60.08 (2 . 71) vs 44.95 (5 . 19); 120 mins, 64.52 (5 .66) vs 46.57 (6.77) for 0.13% vs 0.35%, respectively) . Conclusion Irrigation with 0.13% diluted povidone-iodine every 30 minutes provides the optimal balance between antimicrobial efficacy against MSSA and minimal cytotoxicity, making it the most effective strategy for preventing PJI during surgery. This study highlights the critical role of timing and frequency in povidone

FAQs

What was the main aim of the study?

To determine how the timing of intraoperative irrigation with dilute povidone-iodine affects bacterial eradication and to identify the most effective timing and concentration in an in vitro model.

How were irrigation timing and concentrations tested?

Ti-6Al-4V washers were exposed to MSSA and irrigated with saline, 0.13% povidone-iodine, or 0.35% povidone-iodine for 3 minutes within time patterns of 15, 30, 60, or 120 minutes, with exposure repeated until 120 minutes elapsed.

What irrigation strategy provided the best balance of efficacy and safety?

Irrigation with 0.13% diluted povidone-iodine every 30 minutes provided the optimal balance between antimicrobial efficacy against MSSA and minimal cytotoxicity, supporting prevention of PJI during surgery.

Sep 29, 2026

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