Intraoperative Methylene Blue Staining for Visualization of Microbial Biofilm-associated Tissue in Periprosthetic Joint Infection

Educational Objectives

The goal of this program is to improve treatment of patients with periprosthetic joint infection. After hearing and assimilating this program, the clinician will be better able to:

1. Use methylene blue to identify biofilms in patients with periprosthetic joint infection.

Summary

Periprosthetic infection of joints: incidence at 2 yr after primary total hip or knee replacement 1% to 2%; risk higher after revision; incidence and total number of cases increasing

Options for treatment: incision and drainage with exchange of modular components — used for management of acute postoperative or hematogenous infections; performed before formation of bacterial glycocalyx; removal of modular components and debridement of tissue facilitate restoration of equilibrium and allow action of antibiotic drugs; 1- or 2-stage revision — used for management of chronic infections; 1-stage revision ideal; 2-stage revision gold standard in United States (but expensive and associated with risk for morbidity)

Biofilm: found on all prosthetic devices in chronic infectious states; can also cover host tissue; failure to address biofilm on host tissue likely to cause failure of surgery and return of infection

Methylene blue: used to stain dental biofilm; can stain bacterial biofilm in vivo and in vitro; used by surgeons in total joint replacement to stain sinus tracts and guide debridement; dye exclusion test used by brewers to identify dead and nonviable cells in fermentation of beer

Parry et al (2017): found methylene blue could stain biofilm of Staphylococcus epidermidis on polyethylene, cobalt chrome, bone cement, and polytetrafluoroethylene (Teflon); no negative effect on data from cultures found

Speaker’s study: prospective cohort study designed to investigate methylene blue–guided surgical debridement as novel antibiofilm technique and to evaluate clinical success based on eradication of infection and rate of infection-free survival; mean clinical follow-up ≈22 mo; findings — significantly more bacteria found in tissue stained with methylene blue compared with unstained tissue based on semiquantitative culture; 9-fold higher bioburden of Staphylococcus species found in stained compared with unstained tissue based on quantitative real-time polymerase chain reaction; stained tissue found to contain majority of inflammation; early clinical eradication of infection found in 100% of patients; all patients had culture-negative results of aspiration before revision and normalization of white blood cell count, erythrocyte sedimentation rate, and C-reactive protein level; 5 patients required additional surgery; 3 patients acquired subsequent infection with different organisms

Readings

Gbejuade HO et al: The role of microbial biofilms in prosthetic joint infections. Acta Orthop 2015 Apr;86(2):147-58; McConoughey SJ et al: Biofilms in periprosthetic orthopedic infections. Future Microbiol 2014;9(8):987-1007; Parry JA et al: Disclosing agents for the intraoperative identification of biofilms on orthopedic implants. J Arthroplasty 2017 Mar 16:[Epub ahead of print].

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Shaw was recorded at the 62nd Annual LeRoy C. Abbott Society Scientific Program and 38th Annual Verne T. Inman Lectureship, held May 11-12, 2017, in San Francisco, CA, and presented by the Department of Orthopaedic Surgery, University of California, San Francisco, School of Medicine, and the LeRoy C. Abbott Society. For information about upcoming CME opportunities from the University of California, San Francisco, please visit meded.ucsf.edu/cme. The Audio Digest Foundation thanks the speakers, the Department of Orthopaedic Surgery, University of California, San Francisco, School of Medicine, and the LeRoy C. Abbott Society for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OR401703

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation