High Prevalence of Biofilms on Retrieved Implants from Aseptic Pseudarthrosis Cases

Aakash Agarwal; Megan Mooney; Ashish G Agarwal; Daksh Jayaswal; Gayane Saakyan; Vijay Goel; Jeffrey C Wang; Neel Anand; Steve Garfin; Vithal Shendge; Hossein Elgafy

doi:10.22603/ssrr.2020-0147

High Prevalence of Biofilms on Retrieved Implants from Aseptic Pseudarthrosis Cases

Spine Surg Relat Res. 2020 Sep 23;5(2):104-108. doi: 10.22603/ssrr.2020-0147. eCollection 2021.

Authors

Affiliations

¹ Department of Bioengineering and Orthopaedics Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, USA.
² Primus Super Speciality Hospital, New Delhi, India.
³ USC Spine Center, Los Angeles, USA.
⁴ Spine Center, Cedars Sinai Medical Center, Los Angeles, USA.
⁵ Department of Orthopaedics, University of California, San Diego, USA.

Abstract

Introduction: Recent literature has associated pseudarthrosis and pedicle screw loosening with subchronic infection at the pedicle of the vertebra. The positive culture results of a previous retrieval analysis show that such patients have a high frequency of bacterial contamination. The objective of this study is to visually capture the architecture of these undiagnosed infections, which have been described in other studies as biofilms on supposedly "aseptic" screw loosening.

Methods: Explants from 10 consecutive patients undergoing revision spine surgery for pseudarthrosis were collected and fixed in glutaraldehyde solution. Each of these implants was imaged thoroughly by using scanning electron microscopy and x-ray spectroscopy to evaluate the architecture of the biofilm. Additionally, eight patient swabs from tissues around the implants were sent for cultures to assess bacterial infiltration in tissues beyond the biofilm. The implants were also analyzed using energy dispersive x-ray spectroscopy. The exclusion criteria included clinically diagnosed infection (current or previous) and/or mechanical failure of the implant due to falls/accidents.

Results: The study was successful in capturing the visual architecture of the biofilm on retrieved implants. A total of 77% of pseudarthrosis cases presented with loose pedicle screws, which were diagnosed by a preoperative computed tomography scan showing radiolucency along the screw track and were confirmed intraoperatively, and 72% of the cases showed biofilm on explants.

Conclusions: In the absence of the clinical presentation of infection, impregnated bacteria could form a biofilm around an implant, and this biofilm can remain undetected via contemporary diagnostic methods, including swabbing. Implant biofilm is frequently present in "aseptic" pseudarthrosis cases.

Keywords: Pseudarthrosis; aseptic revision; biofilm; occult infection; readmission; screw loosening; subchronic infection; surgical site infection; undiagnosed infection.