• Andrej Trampuž Division of Infectious Diseases Mayo Clinic Rochester Minnesota USA
  • Martina Kavčič Regional Institute of Public Health 6000 Koper Slovenia
  • Irena Grmek-Košnik Regional Institute of Public Health 4000 Kranj Slovenia
  • Rihard Trebše Orthopedic Hospital Valdoltra 6280 Ankaran Slovenia
Keywords: knee prosthesis, infection, microbiology diagnostics, prosthesis sonicate


Background. Synovial fluid and periprosthetic tissue specimens are the standard specimens cultured for the diagnosis of prosthetic joint infection (PJI). We hypothesize that ultrasonication of the explanted prosthesis may improve diagnosis of PJI by dislodging biofilm bacteria from the prosthesis surface and improve the sensitivity and specificity of diagnosis of PJI.

Methods. Included were patients undergoing knee prosthesis exchange for septic or biomechanical failure and have not received antimicrobial therapy in the last 2 weeks prior specimen collection. Cultures of synovial fluid and periprosthetic tissue specimens were performed per the usual clinical practice. Additionally, explanted joint components were sonicated for 5 minutes at frequency 40 kHz in sterile Ringer’s solution; aliquots of 0.5 ml sonicate were plated onto five aerobic and five anaerobic blood agar plates, and incubated at 37 °C and examined for the next seven days. The number and identity of each colony morphology was recorded.

Results. 35 patients undergoing knee replacement have been studied (24 for aseptic biomechanical failure and 11 for suspected PJI). In patients with PJI, coagulase-negative staphylococci (7 cases), Corynebacterium spp. (2 cases), Staphylococcus aureus (1 case), and viridans group streptococcus (1 case) were recovered. Culture sensitivity and specificity were for synovial fluid 88% and 100%, for periprosthetic tissue 83% and 81%, and for explant sonicate 91% and 100%, respectively. In sonicate cultures higher numbers of microorganisms than in periprosthetic tissue cultures were consistently detected.

Conclusions. Using synovial fluid, periprosthetic tissue, and explant sonicate cultures, 12%, 17% and 9% of PJI were missed, respectively. Explant sonicate cultures were the most sensitive with respect to the diagnosis of PJI, indicating that explant ultrasonication may improve bacterial recovery. In sonicate cultures, infecting organisms were detected in high numbers, typically concentrated on only one of the prosthetic components. These findings indicate that explant ultrasonication may improve bacterial recovery and support the importance of biofilms in, and the focal nature of, PJI.


Download data is not yet available.


Laupacis A, Bourne R, Rorabeck C et al. The effect of elective total hip replacement on health-related quality of life. J Bone Joint Surg Am 1993; 75: 1619–26.

Steckelberg JM, Osmon DR. Prosthetic joint infections. In: Bisno AL, Waldvogel FA eds. Infections associated with indwelling medical devices. Washington: American Society for Microbiology, 1994: 259–90.

Atkins BL, Athanasou N, Deeks JJ et al. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. The OSIRIS Collaborative Study Group. J Clin Microbiol 1998; 36: 2932–9.

Sculco TP. The economic impact of infected joint arthroplasty. Orthopedics 1995; 18: 871–3.

Bauer TW, Schils J. The pathology of total joint arthroplasty. I. Mechanisms of implant fixation. Skeletal Radiol 1999; 28: 423–32.

Kadoya Y, Kobayashi A, Ohashi H. Wear and osteolysis in total joint replacements. Acta Orthop Scand Suppl 1998; 278: 1–16.

Bauer TW, Schils J. The pathology of total joint arthroplasty. II. Mechanisms of implant failure. Skeletal Radiol 1999; 28: 483–97.

Rand JA, Ilstrup DM. Survivorship analysis of total knee arthroplasty. Cumulative rates of survival of 9200 total knee arthroplasties. J Bone Joint Surg Am 1991; 73: 397–409.

Hanssen AD, Rand JA. Evaluation and treatment of infection at the site of a total hip or knee arthroplasty. Instr Course Lect 1999; 48: 111–22.

Segawa H, Tsukayama DT, Kyle RF, Becker DA, Gustilo RB. Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections. J Bone Joint Surg Am 1999; 81: 1434–45.

Lachiewicz PF, Rogers GD, Thomason HC. Aspiration of the hip joint before revision total hip arthroplasty. Clinical and laboratory factors influencing attainment of a positive culture. J Bone Joint Surg Am 1996; 78: 749–54.

Berbari EF, Hanssen AD, Duffy MC et al. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis 1998; 27: 1247–54.

Costerton JW, Lewandowski Z, Caldwell DE, Korber DR, Lappin-Scott HM. Microbial biofilms. Annu Rev Microbiol 1995; 49: 711–45.

Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of persistent infections. Science 1999; 284: 1318–22.

Gristina AG. Biomaterial-centered infection: microbial adhesion versus tissue integration. Science 1987; 237: 1588–95.

Davies DG, Parsek MR, Pearson JP, Iglewski BH, Costerton JW, Greenberg EP. The involvement of cell-to-cell signals in the development of a bacterial biofilm. Science 1998; 280: 295–8.

Donlan RM, Costerton JW. Biofilms: survival mechanisms of clinically relevant microorganisms. Clin Microbiol Rev 2002; 15: 167–93.

Stewart PS, Costerton JW. Antibiotic resistance of bacteria in biofilms. Lancet 2001; 358: 135–8.

Ceri H, Olson ME, Stremick C, Read RR, Morck D, Buret A. The Calgary Biofilm Device: new technology for rapid determination of antibiotic susceptibilities of bacterial biofilms. J Clin Microbiol 1999; 37: 1771–6.

Tunney MM, Ramage G, Patrick S, Nixon JR, Murphy PG, Gorman SP. Antimicrobial susceptibility of bacteria isolated from orthopedic implants following revision hip surgery. Antimicrob Agents Chemother 1998; 42: 3002–5.

Spangehl MJ, Masterson E, Masri BA, O’Connell JX, Duncan CP. The role of intraoperative gram stain in the diagnosis of infection during revision total hip arthroplasty. J Arthroplasty 1999; 14: 952–6.

Burger RR, Basch T, Hopson CN. Implant salvage in infected total knee arthroplasty. Clin Orthop 1991; 273: 105–12.

Tattevin P, Cremieux AC, Pottier P, Huten D, Carbon C. Prosthetic joint infection: when can prosthesis salvage be considered? Clin Infect Dis 1999; 29: 292–5.

Zimmerli W. Prosthetic device infections. In: Root RK eds. Clinical infectious diseases. New York: Oxford University Press, 1999: 801–8.

Dougados M. Synovial fluid cell analysis. Baillieres Clin Rheumatol 1996; 10: 519–34.

McCarty DJ. Synovial fluid. In: Koopman WJ eds. Arthritis and allied conditions: a textbook of rheumatology. Philadelphia: Lippincott Williams & Wilkins, 2001: 83–104.

Windsor RE, Insall JN, Urs WK, Miller DV, Brause BD. Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection. Further follow-up and refinement of indications. J Bone Joint Surg Am 1990; 72: 272–8.

Duff GP, Lachiewicz PF, Kelley SS. Aspiration of the knee joint before revision arthroplasty. Clin Orthop 1996: 132–9.

Mackowiak PA, Jones SR, Smith JW. Diagnostic value of sinus-tract cultures in chronic osteomyelitis. JAMA 1978; 239: 2772–5.

Athanasou NA, Pandey R, de Steiger R, Crook D, Smith PM. Diagnosis of infection by frozen section during revision arthroplasty. J Bone Joint Surg Br 1995; 77: 28–33.

Spangehl MJ, Masri BA, O’Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am 1999; 81: 672–83.

Tunney MM, Patrick S, Curran MD et al. Detection of prosthetic hip infection at revision arthroplasty by immunofluorescence microscopy and PCR amplification of the bacterial 16S rRNA gene. J Clin Microbiol 1999; 37: 3281–90.

Fitzgerald RH, Jr. Infections of hip prostheses and artificial joints. Infect Dis Clin North Am 1989; 3: 329–38.

Isiklar ZU, Darouiche RO, Landon GC, Beck T. Efficacy of antibiotics alone for orthopaedic device related infections. Clin Orthop 1996; 332: 184–9.

Dobbins JJ, Seligson D, Raff MJ. Bacterial colonization of orthopedic fixation devices in the absence of clinical infection. J Infect Dis 1988; 158: 203–5.

Tunney MM, Patrick S, Gorman SP, et al. Improved detection of infection in hip replacements. A currently underestimated problem. J Bone Joint Surg Br 1998; 80: 568–72.

Nguyen LL, Nelson CL, Saccente M, Smeltzer MS, Wassell DL, McLaren SG. Detecting bacterial colonization of implanted orthopaedic devices by ultrasonication. Clin Orthop 2002; 403: 29–37.

Sherertz RJ, Raad II, Belani A et al. Three-year experience with sonicated vascular catheter cultures in a clinical microbiology laboratory. J Clin Microbiol 1990; 28: 76–82.

Padberg FT, Jr., Smith SM, Eng RH. Optimal method for culturing vascular prosthetic grafts. J Surg Res 1992; 53: 384–90.

Gorman SP, Adair CG, Mawhinney WM. Incidence and nature of peritoneal catheter biofilm determined by electron and confocal laser scanning microscopy. Epidemiol Infect 1994; 112: 551–9.

Keane PF, Bonner MC, Johnston SR, Zafar A, Gorman SP. Characterization of biofilm and encrustation on ureteric stents in vivo. Br J Urol 1994; 73: 687–91.

Cardo DM, Sehulster LM. Central sterile supply. In: Mayhall CG eds. Hospital epidemiology and infection control. Philadelphia: Lippincott Williams & Wilkins, 1999: 1023–30.

Pitt WG, McBride MO, Lunceford JK, Roper RJ, Sagers RD. Ultrasonic enhancement of antibiotic action on gram-negative bacteria. Antimicrob Agents Chemother 1994; 38: 2577–82.

Qian Z, Sagers RD, Pitt WG. The effect of ultrasonic frequency upon enhanced killing of P. aeruginosa biofilms. Ann Biomed Eng 1997; 25: 69–76.

Johnson LL, Peterson RV, Pitt WG. Treatment of bacterial biofilms on polymeric biomaterials using antibiotics and ultrasound. J Biomater Sci Polym Ed 1998; 9: 1177–85.

Rediske AM, Roeder BL, Brown MK et al. Ultrasonic enhancement of antibiotic action on Escherichia coli biofilms: an in vivo model. Antimicrob Agents Chemother 1999; 43: 1211–4.

Rediske AM, Roeder BL, Nelson JL et al. Pulsed ultrasound enhances the killing of Escherichia coli biofilms by aminoglycoside antibiotics in vivo. Antimicrob Agents Chemother 2000; 44: 771–2.

Qian Z, Sagers RD, Pitt WG. Investigation of the mechanism of the bioacoustic effect. J Biomed Mater Res 1999; 44: 198–205.

Ogden JA, Toth-Kischkat A, Schultheiss R. Principles of shock wave therapy. Clin Orthop 2001; 387: 8–17.

Ogden JA, Alvarez RG, Levitt R, Marlow M. Shock wave therapy (orthotripsy) in musculoskeletal disorders. Clin Orthop 2001; 387: 22–40.

Thiel M. Application of shock waves in medicine. Clin Orthop 2001: 18–21.

Rompe JD, Rosendahl T, Schollner C, Theis C. High-energy extracorporeal shock wave treatment of nonunions. Clin Orthop 2001; 387: 102–11.

Bergamini TM, Bandyk DF, Govostis D, Vetsch R, Towne JB. Identification of Staphylococcus epidermidis vascular graft infections: a comparison of culture techniques. J Vasc Surg 1989; 9: 665–70.

Benov L, Al Ibraheem J. Disrupting Escherichia coli: A comparison of methods. J Biochem Mol Biol 2002; 35: 428–31.

Blenkinsopp SA, Khoury AE, Costerton JW. Electrical enhancement of biocide efficacy against Pseudomonas aeruginosa biofilms. Appl Environ Microbiol 1992; 58: 3770–3.

Khoury AE, Lam K, Ellis B, Costerton JW. Prevention and control of bacterial infections associated with medical devices. ASAIO J 1992; 38: M174–M178.

McLeod BR, Fortun S, Costerton JW, Stewart PS. Enhanced bacterial biofilm control using electromagnetic fields in combination with antibiotics. Methods Enzymol 1999; 310: 656–70.

Wattanakaroon W, Stewart PS. Electrical enhancement of Streptococcus gordonii biofilm killing by gentamicin. Arch Oral Biol 2000; 45: 167–71.

Yasuda H, Ajiki Y, Koga T, Yokota T. Interaction between clarithromycin and biofilms formed by Staphylococcus epidermidis. Antimicrob Agents Chemother 1994; 38: 138–41.

Yasuda H, Ajiki Y, Koga T, Kawada H, Yokota T. Interaction between biofilms formed by Pseudomonas aeruginosa and clarithromycin. Antimicrob Agents Chemother 1993; 37: 1749–55.

Singh PK, Parsek MR, Greenberg EP, Welsh MJ. A component of innate immunity prevents bacterial biofilm development. Nature 2002; 417: 552–5.

Parsek MR, Greenberg EP. Acyl-homoserine lactone quorum sensing in gram-negative bacteria: a signaling mechanism involved in associations with higher organisms. Proc Natl Acad Sci USA 2000; 97: 8789–93.

Wolz C, Goerke C, Landmann R, Zimmerli W, Fluckiger U. Transcription of clumping factor A in attached and unattached Staphylococcus aureus in vitro and during device-related infection. Infect Immun 2002; 70: 2758–62.

Davies DG, Geesey GG. Regulation of the alginate biosynthesis gene algC in Pseudomonas aeruginosa during biofilm development in continuous culture. Appl Environ Microbiol 1995; 61: 860–7.

Becker P, Hufnagle W, Peters G, Herrmann M. Detection of differential gene expression in biofilm-forming versus planktonic populations of Staphylococcus aureus using micro-representational-difference analysis. Appl Environ Microbiol 2001; 67: 2958–65.

Drenkard E, Ausubel FM. Pseudomonas biofilm formation and antibiotic resistance are linked to phenotypic variation. Nature 2002; 416: 740–3.

Kolbert CP, Rys PN, Hopkins MK et al. 16S ribosomal DNA sequence analysis for identification of bacteria in a clinical microbiology laboratory. In: Persing DH, Tenover FC, Relman DA et al eds. Diagnostic molecular microbiology: principles and applications. American Society for Microbiology, 2002, in press.

How to Cite
Original article

Most read articles by the same author(s)