Are Sonication Cultures of Antibiotic Cement Spacers Useful During Second-stage Reimplantation Surgery for Prosthetic Joint Infection?
Authors: Olsen Adam S. , Wilson Alan , O'Malley Michael J. , Urish Kenneth L. , Klatt Brian A. 
Published: June 2018

Background
Organisms may persist on polymethylmethacrylate (PMMA) spacer surfaces, and subclinical infection is postulated to be a source of infection recurrence. Several small patient series have shown a high proportion of positive sonication cultures on PMMA spacers at the second stage of a two-stage revision. However, the association between a positive sonication culture and the risk for recurrence of infection after two-stage exchange is not fully elucidated.

Questions/purposes
Are cultures derived from sonication of antibiotic spacers associated with infection control or recurrence after two-stage revision for prosthetic joint infection (PJI)?

Methods
Between September 2013 and April 2016, we treated 67 patients with PJI with two-stage revisions. At the second stage, all cement spacers were explanted and sonicated. A total of`10 (15%) patients were lost to followup or failed to reach 1-year followup during the study period, and another 16 (24%) were excluded for prespecified reasons, leaving 41 patients for analysis in this study. Of the 41 patients included in this study, there were 25 TKAs, 15 THAs, and one distal femoral replacement. All patients met the Musculoskeletal Infection Society criteria for PJI at Stage 1 of the two-stage revision. The most common infecting organisms prompting two-stage revision were methicillin-sensitive Staphylococcus aureus and coagulase-negative staphylococci. PMMA spacers were most frequently loaded with gentamicin or gentamicin/vancomycin. Standard 6-week intravenous antibiotic courses were used for index infections and postreimplantation suppression was used for 3 months in all patients as determined by cultures and sensitivities. Patients were assessed for recurrence of infection at postoperative clinic visits completed at standard intervals. The average length of followup was 1.9 years with a range of 1 to 3.3 years.

Results
Sonication cultures that reached a threshold of 5 colony-forming units for positive culture had poor screening utility for subclinical persistent infection (sensitivity: 0%; confidence interval [CI], 0%–60%), but reasonable use for ruling in successful two-stage revision (specificity: 95%; 95% CI, 82%–99%). Positive sonication culture results in the two of 41 (4.9%) explanted spacers yielded coagulase-negative staphylococci, different from primary prosthesis cultures in both patients (Corynebacterium and Proteus mirabilis), and did not alter antibiotic choice. Neither of the patients has developed a reinfection at followup of 1.2 and 1.9 years. Of the 39 two-stage revisions with negative spacer sonication cultures, four developed reinfections.

Conclusions
Positive sonication fluid culture of PMMA spacers during reimplantation surgery was not associated with persistent or recurrent infection at minimum followup of 1 year. We do not recommend routine sonication of explanted PMMA spacers in the absence of clinical evidence suggesting persistent infection. Multicenter, prospective studies with long-term followup are needed to determine if sonication of PMMA spacers can predict persistent or recurrent infection.

Level of Evidence
Level III, diagnostic study.