Novel Use of a Citrate-Based Irrigation Solution During a Hurricane-Related Saline Shortage: A Controlled Cohort Study in Primary Total Knee Arthroplasty

Background Hurricane Helene disrupted intravenous fluid manufacturing in the United States, resulting in a nationwide saline shortage. During this period, our institution temporarily substituted a citrate-based irrigation solution in place of normal saline for primary total knee arthroplasty (TKA). Because no prior clinical data exist evaluating the use of this solution as a saline substitute in arthroplasty, this study represents a natural experiment assessing its short-term outcomes and safety profile. Methods We retrospectively reviewed consecutive primary TKAs performed by four surgeons at a single institution, comparing patients treated solely with the citrate-based irrigation during the fluid shortage (October 2024–February 2025) to a preceding saline control cohort (October 2023–September 2024). Outcomes included periprosthetic joint infection (PJI), emergency department (ED) visits, readmissions, and reoperation. Multivariable logistic regression was performed. Results A total of 1,152 patients were included, including 266 receiving citrate-based irrigation and 886 receiving saline. Baseline demographic and clinical characteristics were similar between groups. The citrate-based irrigation was not associated with increased odds of PJI at 1 year (OR 0.892; 95% CI 0.244–3.257; p=0.863) or return to the operating room (OR 0.859; 95% CI 0.383–1.926; p=0.713) compared with saline. No adverse events attributable to the irrigation solution were noted and ED visits and readmissions potentially related to the irrigation solution did not differ between groups. Conclusions Temporary substitution of a citrate-based solution during a hurricane-related saline shortage was not associated with increased infection, reoperation, or irrigation-related readmission compared with a saline control cohort. While the study may be underpowered to detect small differences in rare events such as PJI, no safety signals were identified.