Pulse Lavage is Inadequate at Removal of Biofilm from the Surface of Total Knee Arthroplasty Materials

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Abstract

In acute periprosthetic infection, irrigation and debridement with component retention has a high failure rate in some studies. We hypothesize that pulse lavage irrigation is ineffective at removing biofilm from total knee arthroplasty (TKA) components. Staphylococcus aureus biofilm mass and location was directly visualized on arthroplasty materials with a photon collection camera and laser scanning confocal microscopy. There was a substantial reduction in biofilm signal intensity, but the reduction was less than a ten-fold decrease. This suggests that irrigation needs to be further improved for the removal of biofilm mass below the necessary bioburden level to prevent recurrence of acute infection in total knee arthroplasty.

Section snippets

Biofilm Culture and Debridement

A clinically isolated methicillin sensitive strain of Staphylococcus aureus (Xen 29, Caliper, Waltham, MA) transfected with luciferase to allow visualization with a bioluminescent photon collection camera was selected. Cobalt chrome metal, polymethyl methacrylate (PMMA), and polyethylene (ultra-high molecular weight polyethylene) coupons (Fig. 1) were inoculated with S. aureus at an absorbance optical density of 0.5 in tryptic soy broth media for 24 hours in an agitating water bath (37 ºC, 30

Results

To test the hypothesis that pulse lavage was ineffective at removing biofilm from TKA components, bioluminescence S. aureus was used to macroscopically visualize and quantify biofilm debridement (Fig. 1). A large bioluminescent signal could be visualized following pulse lavage on PMMA and polyethylene. The signal on the cobalt coupons was below the visible threshold scale to allow comparison to the other materials, but still did have a signal above control comparisons as discussed below.

The

Discussion

The establishment of a biofilm on TKA components is believed to be responsible for the high failure rate of single stage irrigation and debridement with component retention. The inability of pulse lavage to remove substantial mass of biofilm from TKA components is anecdotally held, but there is a remarkable absence of evidence supporting this hypothesis in the literature. Our results used direct visualization and quantification of the remaining biofilm to demonstrate pulse lavage irrigation

Acknowledgments

The authors would like to thank Warren O. Haggard PhD with the Department of Biomedical Engineering at the University of Memphis for his expert technical assistance with bioluminescent bacteria and imaging.

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    Funding support was provided in part by the Woodward Family Endowment in Biomedical Engineering and the Pellegrini Endowment to the Department of Orthopaedics and Rehabilitation at the Pennsylvania State University. Laboratory facilities and equipment were partially provided by Dr. Dani Zander, Department of Pathology at the Pennsylvania State College of Medicine.

    The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2013.12.012.

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