Electrical and Electrochemical Control of Orthopedic Implant-Associated Biofilms: Mechanisms, Evidence, and Translational Challenges

Implant-associated biofilms are a major barrier to successful treatment of periprosthetic joint infection (PJI) because surface-adherent microbial communities embedded in extracellular polymeric substance exhibit marked tolerance to antimicrobial therapy and host defenses. Electrical and electrochemical approaches offer a mechanistically distinct strategy for directly disrupting these communities at conductive implant surfaces. This review critically evaluates mechanistic, in vitro, animal, translational, and early clinical evidence for electrical and electrochemical control of implant-associated biofilms, with particular emphasis on orthopedic applications. Low-intensity direct current, cathodic voltage-controlled electrical stimulation, electrolytic cleaning, alternating and pulsed fields, and radiofrequency approaches can promote biofilm detachment, bacterial killing, or antimicrobial sensitization through polarity- and dose-dependent effects involving local pH shifts, electrolysis, reactive species generation, gas evolution, matrix disruption, and altered transport across the biofilm. Experimental studies consistently demonstrate antibiofilm activity on metallic implant surfaces, and animal models provide additional support, particularly for combinations with antibiotics. However, interpretation is constrained by heterogeneous electrical dosing, simplified implant geometries, young or single-species biofilms, variable endpoints, and limited assessment of corrosion and tissue safety. Human evidence remains largely limited to dental peri-implantitis, and no completed clinical trial has established efficacy in hip or knee PJI. Electrical and electrochemical decontamination should therefore be considered promising but investigational adjuncts to surgical source control and antimicrobial therapy in orthopedic periimplantitis. Translation will require standardized dose reporting, clinically realistic biofilm and implant models, rigorous electrochemical and tissue safety assessment, and controlled trials evaluating infection-free implant retention and patient benefit.