Intraoperative Direct Sonication of Implants and Soft Tissue for the Diagnosis of Periprosthetic Joint Infection

Abstract

Background: Sonication is very efficacious for the microbiological diagnosis of periprosthetic joint infection (PJI), but it involves many steps and multiple workplaces and personnel and therefore carries a potential contamination risk. We present an innovative version of the sonication culture method that involves direct sonication of the retrieved implant and soft tissue, without a sonication tube, intraoperatively and incubation using a BACT/ALERT 3D blood culture system to enhance the efficacy of microbiological diagnosis of PJI. Methods:We performed a prospective study of consecutive patients requiring implant removal and classified them as having PJI or aseptic failure according to standard criteria. The removed prosthetic components and adjacent soft tissue were directly sonicated in a small metal container, without a sonication tube, during the operation. The sonication fluid was immediately incubated in blood culture bottles in the operating room and cultured in the BACT/ALERT 3D blood culture system. The synovial fluid was also cultured in the BACT/ALERT 3D system to serve as a comparison.Results: Of the 64 included patients, 36 had PJI and 28 had aseptic failure. Fluid from direct sonication and conventional synovial fluid showed sensitivities of 91.7% and 55.6% (p < 0.001) and specificities of 82.1% and 92.9%, respectively. Fourteen cases of PJI were detected by culture of fluid from direct sonication but not by culture of synovial fluid. Higher sensitivity was obtained by direct sonication of only tissue than by direct sonication of only the implant (88.9% versus 75.0%). No significant difference in detection time was found between Staphylococcus aureus and coagulase-negative Staphylococcus.Conclusions: When combined with incubation in BACT/ALERT bottles, direct intraoperative sonication of implants and soft tissues without a sonication tube was more sensitive than conventional synovial fluid culture and could reliably and rapidly detect the bacteria commonly found in PJI.

Sonication protocols and their contributions to the microbiological diagnosis of implant-associated infections: a review of the current scenario

“…The majority of studies describing the use of the sonication technique for explant prostheses use a sonication bath, often due to sample size constraints. However, it is worth noting that recently, an article demonstrated greater sensitivity with direct intraoperative sonication culture of implants and soft tissues than with conventional synovial fluid culture utilizing a portable probe sonicator (Shanghai Weimi Ultrasonic Co., Ltd.) ( Ji et al., 2023 ).…”

“…Additionally, the application of an innovative version of the sonication culture method involves direct sonication of the retrieved implant and soft tissue, without a sonication tube, intraoperatively. This method utilizes a BACT/ALERT 3D blood culture system, contributing to the increased effectiveness of microbiological diagnosis for PJI ( Drago et al., 2019 ; Ji et al., 2023 ).…”

Current Status and Perspectives of Diagnosis and Treatment of Periprosthetic Joint Infection

“…A prospective multicenter study recommended that best practice is to collect cultures from tissues in contact with material and joint fluid and to have the surgeon inoculate them directly into blood culture bottles, which are then sent to the laboratory for culture. 66 However, antibiotic therapy for PJI poses a significant challenge to the traditional intraoperative culture model. Antibiotic administration reduces bacterial load and mediates bacterial dormancy leading to false-negative results.…”

“…71 Similarly, Li Cao and others found that ultrasound treatment of removed prosthetic components and their surrounding soft tissues in small metal containers directly during surgery, followed by incubation in blood culture flasks in the operating room and culturing in the BACT/ALERT 3D Blood Culture System not only increased the sensitivity rate to 91.7%, but also simplified the traditional ultrasound treatment process and reduced the risk of potential contamination. 66 Chemical methods of treatment refer to the use of strong reducing agents such as dithiothreitol (DTT) to improve the sensitivity of the culture by destabilizing the biofilm, thereby separating the bacteria from the biofilm. Dithiothreitol is https://doi.org/10.2147/IDR.S457644…”

“…A prospective multicenter study recommended that best practice is to collect cultures from tissues in contact with material and joint fluid and to have the surgeon inoculate them directly into blood culture bottles, which are then sent to the laboratory for culture. 66 …”