Insights from the Operating Room: National Survey Results of Orthopedic Surgeons’ Perspective on Intraoperative Wound Irrigation

Dr. David Rodriguez
Associate Professor, Orthopedic Surgery at University of Texas Health, Houston

Periprosthetic joint infections (PJIs) remain a serious complication following arthroplasty surgery, causing significant patient morbidity and economic burden to healthcare systems. Associated costs are estimated to reach $1.85B by 2030 for knee and hips alone. While studies highlight the potential in reducing SSIs, variability in clinical application and the lack of standardized, evidence-based guidelines necessitate a comprehensive understanding of current intraoperative practices including the use of intraoperative wound irrigation (IOWI). How should it be performed? With what solution? What are the ideal characteristics necessary?

Why intraoperative wound irrigation matters

Wound irrigation is widely recognized as a key intraoperative step for reducing bacterial load, removing debris, and optimizing wound healing. Despite its simplicity, the technique varies dramatically across surgeons and institutions.

Numerous studies have shown that proper irrigation can reduce SSIs in various specialties, yet orthopedic practice patterns remain inconsistent due to lack of definitive, large-scale clinical data, variation in surgical training, and differences in irrigation solution instructions.

To better understand current perceptions and practices, a recent national survey of orthopedic surgeons was conducted. This survey aimed to explore surgeon’s irrigation preferences, perceived benefits, and the gap that continues to exist.

Who was surveyed?

The national survey included responses from 112 board-certified orthopedic surgeons performing over 200 total joints annually. Respondents were asked about their routine use of irrigation, preferred solutions, delivery methods, and ideal characteristics of the selected solution.

Key Finding #1: Irrigation is widely used, most frequently at closure

• Over 99% of surgeons reported using some form of irrigation in routine procedures.

• Antiseptic followed by saline rinse was the predominant irrigation method across all surgical phases, with 52% of surgeons applying IOWI at closure, indicating its perceived critical role in final wound decontamination.
• Saline alone was commonly used during prosthesis implantation, while antibiotic-based irrigation was infrequently used; however, the method and solution choice varied.
• Delivery methods ranged from bulb syringes, gravity flow, basins, and pulse lavage. This variation reflects both surgeon preference and absence of institutional protocols.

Key Finding #2: Pulsatile lavage is the preferred delivery method

• Across all surgical phases, pulse lavage was the most utilized delivery system (71% at exposure, 73% at implantation), dropping slightly to 59% at closure.
• Methods of gravity flow or bulb syringe were far less noted, emphasizing a preference for more targeted and pressurized irrigation delivery, with 88% of respondents emphasizing adaptability to methods of delivery.

Key Finding #3: Antiseptics are gaining ground…cautiously

• Saline remains the dominant irrigation solution (1-3L/case); however, there is a growing trend toward antiseptic use, particularly in contaminated wounds or high-risk patients (e.g., increased number of comorbidities, revision surgery).
• Many surgeons expressed concerns about cytotoxicity in primary and non-infected revisions.

Key Finding #4: Biofilm prevention is a key priority in solution selection

• Surgeons ranked biofilm-related capabilities (e.g., disruption, prevention of attachment) and rapid, broad-spectrum antimicrobial activity as the most important features of an ideal irrigant.
• General acceptance that revision cases require an increased emphasis on biofilm disruption at the forfeiture of local tissue toxicity.

Key Finding #5: Strong belief in residual activity, safety, and adjunctive use

• 96% of surgeons agreed antiseptic irrigants complement systemic antibiotics in SSI prevention.
• Consensus was reached on the need for residual antimicrobial activity, biofilm prevention, and solutions that do not harm host tissue or implants.

What is next?

The survey reveals both promising openness and persistent uncertainty surrounding wound irrigation practices. Several implications stand out:

1. Validation

High-quality, specialty-specific data supporting of SSI reduction outcomes are necessary. These will shape future protocols and alignment.

2. Education

Surgeons and surgical teams need clear, evidence-informed guidance on antiseptic concentration, delivery method, dwell times, and rinse protocols. Academic and professional societal entities could lead the way.

3. Standardization

A tiered protocol (e.g., clean, clean-contaminated, contaminated) may offer the right balance between consistency and clinical judgment.

4. Adoption

Conversion of historical preferences to evidence-based methods, exhibiting decrease incidence of infection rates and improved outcomes.

5. Innovation

Any new irrigation product or technique must be adaptable, fast, intuitive, cost-conscious, and compatible with surgical flow in the sterile field, whilst delivering rapid microbial kill, sustained effects, and biofilm penetration.

Conclusion: An evolving practice

Intraoperative wound irrigation remains aligned to the practices of SSI prevention, yet the survey confirms it is often practiced by habit rather than by protocol. Most surgeons recognize its importance, express a desire for better data, and are open to alternatives provided appropriate evidence.

The results offer important insights for quality improvement teams, infection preventionists, and product innovators into wound irrigation decisions in the operating theatre. Expert opinion and consensus need to be sought and where gaps in current product offerings remain.

As healthcare shifts toward value-based outcomes and surgical quality metrics, understanding what surgeons value and require of an intraoperative wound irrigation solution will be essential.

References:

1. Woodmansey, E. et al. Intraoperative wound irrigation in orthopedic surgery: A survey of current understanding and practice across the United States: Submitted to Arthroplasty Today (2025).
2. Purcell, RL. et al. Comparison of Wound Complications and Deep Infections With Direct Anterior and Posterior Approaches in Obese Hip Arthroplasty Patients. J Arthroplasty 33, 220–223 (2018).