The Function of Sonication in the Diagnosis of Periprosthetic Joint Infection After Total Knee Arthroplasty

Document Type : CURRENT CONCEPTS REVIEW

Author

Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain

Abstract

Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a serious adverse event. Culturing of 
samples of periprosthetic tissue is the standard technique utilized for the microbiological diagnosis of PJI. However, 
this technique is neither sensitive nor specific since in PJI the microorganisms are usually in a biofilm on the surface of 
the prosthesis. The objective of this paper is to know the role of sonication in the diagnosis of PJI after TKA. Sonication 
consists in taking samples of bacteria from biofilms adhered to the prosthetic surface. The reported sensitivity for the 
diagnosis of PJI of the periprosthetic tissue cultures and sonicate fluid cultures is 54% and 75%, apiece. The specificity 
is 98% and 87%, respectively. In conclusion, the sonication technique is a dependable test for the diagnosis of PJI 
after TKA with a greater sensitivity and specificity than the conventional periprosthetic tissue cultures. Sonication of 
polyethylene liners, rather than the whole prosthesis, has been reported to be sufficient for diagnosis of prosthetic joint 
infection.
Level of evidence: III

Keywords

Main Subjects

References

  1. Rodrí�guez-Merchán EC, Liddle AD, eds. The Infected 
    Total Knee Arthroplasty, Epidemiology of the infected 
    total knee arthroplasty: incidence, causes, and the 
    burden of disease. 1st ed. Springer International 
    Publishing AG; 2018. DOI: 10.1007/978-3-319-
    66730-0_1.
    2. Trampuz A, Piper KE, Jacobson MJ, et al. Sonication 
    of removed hip and knee prostheses for diagnosis 
    of infection. N Engl J Med 2007; 357:654-663. DOI: 
    10.1056/NEJMoa061588
    3. Portillo ME, Salvadó M, Sorli L, et al. Multiplex PCR 
    of sonication fluid accurately differentiates between 
    prosthetic joint infection and aseptic failure. J Infect 
    2012; 65(6):541-8. doi: 10.1016/j.jinf.2012.08.018
    4. Rondon AJ, Tan TL, Parvizi J, eds. The Infected Total 
    Knee Arthroplasty, Serological markers of infection in 
    the infected total knee arthroplasty. 1st ed. Springer 
    International Publishing AG; 2018. DOI: 10.1007/978-
    3-319-66730-0_9
    5. Gómez-Barrena E, Garcí�a-Rey E, eds. The Infected 
    Total Knee Arthroplasty, Sonication of removed 
    implants in the infected total knee arthroplasty. 1st 
    ed. Springer International Publishing AG; 2018. DOI: 
    10.1007/978-3-319-66730-0_14.
    6. Trampuz A, Piper KE, Hanssen AD, et al. Sonication of 
    explanted prosthetic components in bags for diagnosis 
    of prosthetic joint infection is associated with risk 
    of contamination. Journal of clinical microbiology. 
    J Clin Microbiol 2006; 44(2):628-31. doi: 10.1128/
    JCM.44.2.628-631.2006..
    7. Holinka J, Bauer L, Hirschl AM, Graninger W, 
    Windhager R, Presterl E. Sonication cultures of 
    explanted components as an add-on test to routinely 
    conducted microbiological diagnostics improve 
    pathogen detection. J Orthop Res 2011; 29(4):617-22. 
    doi: 10.1002/jor.21286. Epub 2010 Dec 7.
    8. Van Diek FM, Albers CG, Van Hooff ML, Meis JF, 
    Goosen JH. Low sensitivity of implant sonication 
    when screening for infection in revision 
    surgery. Acta Orthop 2017; 88(3):294-299. doi: 
    10.1080/17453674.2017.1300021.
    9. Tani S, Lepetsos P, Stylianakis A, Vlamis J, Birbas K, 
    Kaklamanos I. Superiority of the sonication method 
    against conventional periprosthetic tissue cultures for 
    diagnosis of prosthetic joint infections. Eur J Orthop 
    Surg Traumatol 2018; 28(1):51-57. doi: 10.1007/
    s00590-017-2012-y.
    10.Park HJ, Kim HJ, Kim S, et al. Safety of temporary 
    use of recycled autoclaved femoral components in 
    infected total knee arthroplasty: confirming sterility 
    using a sonication method. Clin Orthop Surg 2018; 
    10(4):427-432. doi: 10.4055/cios.2018.10.4.427.
    11.Achermann Y, Vogt M, Leunig M, Wüst J, Trampuz A. 
    Improved diagnosis of periprosthetic joint infection 
    by multiplex PCR of sonication fluid from removed 
    implants. J Clin Microbiol 2010; 48(4):1208-14. doi: 
    10.1128/JCM.00006-10.
    12.Nelson CL, Jones RB, Wingert NC, Foltzer M, Bowen 
    TR. Sonication of antibiotic spacers predicts failure 
    during two-stage revision for prosthetic knee and hip 
    infections. Clin Orthop Relat Res 2014; 472(7):2208-
    14. DOI: 10.1007/s11999-014-3571-4.
    13.Karbysheva S, Grigoricheva L, Golnik V, Popov S, 
    Renz N, Trampuz A. Influence of retrieved hip-and 
    knee-prosthesis biomaterials on microbial detection 
    by sonication. Eur Cell Mater 2019; 37:16-22. doi: 
    10.22203/eCM.v037a02.
    14.Š�uster K, Podgornik A, Cör A. Quick bacteriophagemediated bioluminescence assay for detecting 
    Staphylococcus spp. in sonicate fluid of orthopaedic 
    artificial joints. New Microbiol 2017; 40(3):190-196. 
    15.Rodrí�guez-Merchán EC, Liddle AD, eds. The Infected 
    Total Knee Arthroplasty, Microbiological concepts of 
    the infected total knee arthroplasty. 1st ed. Springer 
    International Publishing AG; 2018. DOI: 10.1007/978-
    3-319-66730-0_2
    16.Putnis SE, Oussedik S, eds. The Infected Total Knee 
    Arthroplasty, Preoperative Optimization to Prevent 
    an Infected Total Knee Arthroplasty: Host Factors. 1st 
    ed. Springer International Publishing AG; 2018. DOI: 
    10.1007/978-3-319-66730-0_3
    17.Vaquero-Picado A, Rodrí�guez-Merchán EC, eds. The 
    Infected Total Knee Arthroplasty, Antibiotic pophylaxis 
    to prevent infection in total knee arthroplasty. Springer 
    International Publishing AG, Cham, Switzerland, 
    2018, pp 36-46. DOI: 10.1007/978-3-319-66730-0_5.
    18.Petis SM, Abdel MP, eds. The Infected Total Knee 
    Arthroplasty, Clinical Diagnosis of the Infected Total 
    Knee Arthroplasty. 1st ed. Springer International 
    Publishing AG; 2018. DOI: 10.1007/978-3-319-
    66730-0_7
    19.Ruiz-Pérez JS, Agüera-Gavaldá M, Rodrí�guez-Merchán 
    EC, eds. The Infected Total Knee Arthroplasty, The 
    Role of Knee Aspiration in the Infected Total Knee 
    Arthroplasty. 1st ed. Springer International Publishing 
    AG; 2018. DOI: 10.1007/978-3-319-66730-0_10
    20.Subramanian P, Patel R, eds. The Infected Total Knee 
    Arthroplasty, Histological Diagnosis in the Infected 
    Total Knee Arthroplasty. 1st ed. Springer International 
    Publishing AG; 2018. DOI: 10.1007/978-3-319-
    66730-0_12 
    21.Raymond AC, Oussedik S, eds. The Infected Total 
    Knee Arthroplasty, Intraoperative Cultures for the 
    Suspected Total Knee Arthroplasty Infection. 1st ed. 
    Springer International Publishing AG; 2018. DOI: 
    10.1007/978-3-319-66730-0_13 
    22.Parvizi J, Gehrke T, Chen AF. Proceedings of the 
    international consensus on periprosthetic joint 
    infection. Bone Joint J 2013; 95-B(11):1450-2. doi: 
    10.1302/0301-620X.95B11.33135.
    23.Mariconda M, Ascione T, Balato G, et al. Sonication 
    of antibiotic-loaded cement spacers in a two-stage 1. Rodrí�guez-Merchán EC, Liddle AD, eds. The Infected 
    Total Knee Arthroplasty, Epidemiology of the infected 
    total knee arthroplasty: incidence, causes, and the 
    burden of disease. 1st ed. Springer International 
    Publishing AG; 2018. DOI: 10.1007/978-3-319-
    66730-0_1.
    2. Trampuz A, Piper KE, Jacobson MJ, et al. Sonication 
    of removed hip and knee prostheses for diagnosis 
    of infection. N Engl J Med 2007; 357:654-663. DOI: 
    10.1056/NEJMoa061588
    3. Portillo ME, Salvadó M, Sorli L, et al. Multiplex PCR 
    of sonication fluid accurately differentiates between 
    prosthetic joint infection and aseptic failure. J Infect 
    2012; 65(6):541-8. doi: 10.1016/j.jinf.2012.08.018
    4. Rondon AJ, Tan TL, Parvizi J, eds. The Infected Total 
    Knee Arthroplasty, Serological markers of infection in 
    the infected total knee arthroplasty. 1st ed. Springer 
    International Publishing AG; 2018. DOI: 10.1007/978-
    3-319-66730-0_9
    5. Gómez-Barrena E, Garcí�a-Rey E, eds. The Infected 
    Total Knee Arthroplasty, Sonication of removed 
    implants in the infected total knee arthroplasty. 1st 
    ed. Springer International Publishing AG; 2018. DOI: 
    10.1007/978-3-319-66730-0_14.
    6. Trampuz A, Piper KE, Hanssen AD, et al. Sonication of 
    explanted prosthetic components in bags for diagnosis 
    of prosthetic joint infection is associated with risk 
    of contamination. Journal of clinical microbiology. 
    J Clin Microbiol 2006; 44(2):628-31. doi: 10.1128/
    JCM.44.2.628-631.2006..
    7. Holinka J, Bauer L, Hirschl AM, Graninger W, 
    Windhager R, Presterl E. Sonication cultures of 
    explanted components as an add-on test to routinely 
    conducted microbiological diagnostics improve 
    pathogen detection. J Orthop Res 2011; 29(4):617-22. 
    doi: 10.1002/jor.21286. Epub 2010 Dec 7.
    8. Van Diek FM, Albers CG, Van Hooff ML, Meis JF, 
    Goosen JH. Low sensitivity of implant sonication 
    when screening for infection in revision 
    surgery. Acta Orthop 2017; 88(3):294-299. doi: 
    10.1080/17453674.2017.1300021.
    9. Tani S, Lepetsos P, Stylianakis A, Vlamis J, Birbas K, 
    Kaklamanos I. Superiority of the sonication method 
    against conventional periprosthetic tissue cultures for 
    diagnosis of prosthetic joint infections. Eur J Orthop 
    Surg Traumatol 2018; 28(1):51-57. doi: 10.1007/
    s00590-017-2012-y.
    10.Park HJ, Kim HJ, Kim S, et al. Safety of temporary 
    use of recycled autoclaved femoral components in 
    infected total knee arthroplasty: confirming sterility 
    using a sonication method. Clin Orthop Surg 2018; 
    10(4):427-432. doi: 10.4055/cios.2018.10.4.427.
    11.Achermann Y, Vogt M, Leunig M, Wüst J, Trampuz A. 
    Improved diagnosis of periprosthetic joint infection 
    by multiplex PCR of sonication fluid from removed 
    implants. J Clin Microbiol 2010; 48(4):1208-14. doi: 
    10.1128/JCM.00006-10.
    12.Nelson CL, Jones RB, Wingert NC, Foltzer M, Bowen 
    TR. Sonication of antibiotic spacers predicts failure 
    during two-stage revision for prosthetic knee and hip 
    infections. Clin Orthop Relat Res 2014; 472(7):2208-
    14. DOI: 10.1007/s11999-014-3571-4.
    13.Karbysheva S, Grigoricheva L, Golnik V, Popov S, 
    Renz N, Trampuz A. Influence of retrieved hip-and 
    knee-prosthesis biomaterials on microbial detection 
    by sonication. Eur Cell Mater 2019; 37:16-22. doi: 
    10.22203/eCM.v037a02.
    14.Š�uster K, Podgornik A, Cör A. Quick bacteriophagemediated bioluminescence assay for detecting 
    Staphylococcus spp. in sonicate fluid of orthopaedic 
    artificial joints. New Microbiol 2017; 40(3):190-196. 
    15.Rodrí�guez-Merchán EC, Liddle AD, eds. The Infected 
    Total Knee Arthroplasty, Microbiological concepts of 
    the infected total knee arthroplasty. 1st ed. Springer 
    International Publishing AG; 2018. DOI: 10.1007/978-
    3-319-66730-0_2
    16.Putnis SE, Oussedik S, eds. The Infected Total Knee 
    Arthroplasty, Preoperative Optimization to Prevent 
    an Infected Total Knee Arthroplasty: Host Factors. 1st 
    ed. Springer International Publishing AG; 2018. DOI: 
    10.1007/978-3-319-66730-0_3
    17.Vaquero-Picado A, Rodrí�guez-Merchán EC, eds. The 
    Infected Total Knee Arthroplasty, Antibiotic pophylaxis 
    to prevent infection in total knee arthroplasty. Springer 
    International Publishing AG, Cham, Switzerland, 
    2018, pp 36-46. DOI: 10.1007/978-3-319-66730-0_5.
    18.Petis SM, Abdel MP, eds. The Infected Total Knee 
    Arthroplasty, Clinical Diagnosis of the Infected Total 
    Knee Arthroplasty. 1st ed. Springer International 
    Publishing AG; 2018. DOI: 10.1007/978-3-319-
    66730-0_7
    19.Ruiz-Pérez JS, Agüera-Gavaldá M, Rodrí�guez-Merchán 
    EC, eds. The Infected Total Knee Arthroplasty, The 
    Role of Knee Aspiration in the Infected Total Knee 
    Arthroplasty. 1st ed. Springer International Publishing 
    AG; 2018. DOI: 10.1007/978-3-319-66730-0_10
    20.Subramanian P, Patel R, eds. The Infected Total Knee 
    Arthroplasty, Histological Diagnosis in the Infected 
    Total Knee Arthroplasty. 1st ed. Springer International 
    Publishing AG; 2018. DOI: 10.1007/978-3-319-
    66730-0_12 
    21.Raymond AC, Oussedik S, eds. The Infected Total 
    Knee Arthroplasty, Intraoperative Cultures for the 
    Suspected Total Knee Arthroplasty Infection. 1st ed. 
    Springer International Publishing AG; 2018. DOI: 
    10.1007/978-3-319-66730-0_13 
    22.Parvizi J, Gehrke T, Chen AF. Proceedings of the 
    international consensus on periprosthetic joint 
    infection. Bone Joint J 2013; 95-B(11):1450-2. doi: 
    10.1302/0301-620X.95B11.33135.
    23.Mariconda M, Ascione T, Balato G, et al. Sonication 
    of antibiotic-loaded cement spacers in a two-stage
The Archives of Bone and Joint Surgery
Volume 10, Issue 9
September 2022
Pages 735-740

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History

  • Receive Date: 14 November 2019
  • Revise Date: 11 October 2020
  • Accept Date: 14 November 2020

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