Biofilm Related Total Knee Arthroplasty Infection: Prevention, Diagnosis and Treatment

Document Type : In Brief

Author

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

10.22038/abjs.2024.77560.3583

Abstract

Biofilm related implant infection is undoubtedly a relevant challenge in total knee arthroplasty (TKA) 
with our comprehension steadily progressing and novel management approaches being developed. The 
aim of this article was to review the most important advances in approaches to combat infections due 
to biofilm-forming bacteria in TKA. The main conclusions were the following: 1) Fundamental 
management techniques for infected TKA include open DAIR (debridement, antibiotics, and implant 
retention), and one and two-stage revision TKA; 2) Continuous local antibiotic perfusion (CLAP) appears 
to diminish the risk of periprosthetic joint infection (PJI); 3) Restraint of quorum sensing seems to avert 
PJI after TKA; 4) A recent in vitro study showed promising results in the prevention and management of 
PJI after TKA using PMMA [poly(methyl methacrylate)] loaded with up to 100 mg of rifampin.
 Level of evidence: III

Keywords

Main Subjects


1.. Kelmers E, Szuba A, King SW, et al. Smart knee implants: an 
overview of current technologies and future possibilities. 
Indian J Orthop. 2022; 57(5):635-642. doi: 10.1007/s43465-
022-00810-5.
2. Chen JL, Huang TY, Hsu WB, et al. Characterization of 
methicillin-resistant Staphylococcus aureus isolates from 
periprosthetic joint infections. Pathogens. 2022; 11(7):719. 
doi: 10.3390/pathogens11070719.
3. Tsikopoulos K, Christofilos SI, Kitridis D,et al. Is sonication 
superior to dithiothreitol in diagnosis of periprosthetic joint 
infections? A meta-analysis. Int Orthop. 2022; 46(6):1215-
1224. doi: 10.1007/s00264-022-05350-z.
4. Rodriguez-Merchan EC. The function of sonication in the 
diagnosis of periprosthetic joint infection after total knee 
arthroplasty. Arch Bone Jt Surg. 2022; 10(9): 735-740. doi: 
10.22038/abjs.2020.44329.2212.
5. Fisher CR, Salmons HI, Mandrekar J, Greenwood-Quaintance 
KE, Abdel MP, Patel R. A 92 protein inflammation panel 
performed on sonicate fluid differentiates periprosthetic joint 
infection from non-infectious causes of arthroplasty failure. 
Sci Rep. 2022; 12(1):16135. doi: 10.1038/s41598-022-
20444-9.
6. Azad MA, Wolf MJ, Strasburg AP, et al. Comparison of the 
BioFire Joint Infection Panel to 16S ribosomal RNA genebased targeted metagenomic sequencing for testing synovial 
fluid from patients with knee arthroplasty failure. J Clin 
Microbiol. 2022; 60(12):e0112622. doi: 10.1128/jcm.01126-
22.
7. Flurin L, Hemenway JJ, Fisher CR, et al. Clinical use of a 16S 
ribosomal RNA gene-based Sanger and/or next generation 
sequencing assay to test preoperative synovial fluid for 
periprosthetic joint infection diagnosis. mBio. 2022; 
13(6):e0132222. doi: 10.1128/mbio.01322-22.
8. Hong HL, Flurin L, Thoendel MJ, et al. Targeted versus shotgun 
metagenomic sequencing-based detection of microorganisms 
in sonicate fluid for periprosthetic joint infection diagnosis. 
Clin Infect Dis. 2023; 76(3):e1456-e1462. doi: 
10.1093/cid/ciac646.
9. Brooks JR, Chonko DJ, Pigott M, Sullivan AC, Moore K, Stoodley 
P. Mapping bacterial biofilm on explanted orthopedic 
hardware: An analysis of 14 consecutive cases. APMIS. 2023; 
131(4):170-179. doi: 10.1111/apm.13295.
10. Drago L, Romanò D, Fidanza A, et al. Dithiotreitol pretreatment of synovial fluid samples improves microbiological 
counts in peri-prosthetic joint infection. Int Orthop. 2023; 
47(5):1147-1152. doi: 10.1007/s00264-023-05714-z.
11. Fisher CR, Mangalaparthi KK, Greenwood-Quaintance KE, 
Abdel MP, Pandey A, Patel R. Mass spectrometry-based 
proteomic profiling of sonicate fluid differentiates Staphylococcus aureus periprosthetic joint infection from non-infectious failure: a pilot study. Proteomics Clin Appl. 
2023; 17(5):e2200071. doi: 10.1002/prca.202200071.
12. Roitzsch C, Apolle R, Jan Baldus C, et al. Ultrasonic bone 
cement removal efficiency in total joint arthroplasty revision: 
A computer tomographic-based cadaver study. J Orthop Res. 
2023; 41(6):1365-1375. doi: 10.1002/jor.25465.
13. Indelli PF, Ghirardelli S, Valpiana P, Bini L, Festini M, Iannotti, 
F. Debridement, antibiotic pearls, and retention of the 
implant (DAPRI) in the treatment of early periprosthetic joint 
infections: a consecutive series. Pathogens. 2023; 12(4):605. 
doi: 10.3390/pathogens12040605.
14. Ji B, Li G, Zhang X, et al. Effective single-stage revision using 
intra-articular antibiotic infusion after multiple failed surgery 
for periprosthetic joint infection: a mean seven years' followup. Bone Joint J. 2022; 104-B (7):867-874. doi: 
10.1302/0301-620X.104B7.BJJ-2021-1704.R1.
15. Shichman I, Ward SA, Lu L, et al. Failed 2-stage revision knee 
arthroplasty for periprosthetic joint infection-patient 
characteristics and outcomes. J Arthroplasty. 2023; 
38(10):2177-2182. doi: 10.1016/j.arth.2023.04.063.
16. Miyake Y, Takagi T. Treatment experience with continuous 
local antibiotic perfusion for periprosthetic joint infection. J 
Orthop Sci. 2023:S0949-2658(23)00331-7. doi: 
10.1016/j.jos.2023.12.001. 
17.Turner AB, Gerner E, Firdaus R, et al. Role of sodium salicylate 
in Staphylococcus aureus quorum sensing, virulence, biofilm 
formation and antimicrobial susceptibility. Front Microbiol. 
2022:13:931839. doi: 10.3389/fmicb.2022.931839. 
18. Kruse CC, Ekhtiari S, Oral I, et al. The use of rifampin in total 
joint arthroplasty: a systematic review and meta-analysis of 
comparative studies. J Arthroplasty. 2022; 37(8):1650-1657. 
doi: 10.1016/j.arth.2022.03.072.
19. Laperche J, Barrett CC, Boduch A, et al. Mechanically stable 
rifampin antibiotic cement inhibits Pseudomonas aeruginosa 
biofilm surface growth. J Orthop Res. 2024; 42(3):547-554. 
doi: 10.1002/jor.25720. 
20. Charalambous LT, Kim BI, Schwartz AM, et al. Prosthetic knee 
infection with coagulase-negative Staphylococcus: a 
harbinger of poor outcomes. J Arthroplasty. 2022; 
37(6S):S313-S320. doi: 10.1016/j.arth.2022.02.050.