An experimental comparison of different devices for pulsatile high-pressure lavage and their relevance to cement intrusion into cancellous bone

Aseptic Tibial Loosening Is Associated With Thickness of the Cement: A Radiographic Case-Control Study

BACKGROUND

The cementation technique is crucial for achieving adequate fixation and optimal survivorship in total knee arthroplasty (TKA). The thickness of the cement at the tibial bone-implant surface may be related to aseptic tibial loosening. However, to date, no studies have demonstrated a direct association between cement thickness and rates of aseptic tibial loosening.

METHODS

We performed a retrospective review to identify 28,327 primary cemented TKAs with at least 2 years of follow-up at an academic health system from 2013 to 2021. A total of 115 cases underwent revision surgery for aseptic tibial loosening. Cases where the implant was recalled specifically for loosening (n = 23) were excluded. The remaining 92 aseptic tibial loosening cases were 2:1 propensity score matched and implant matched to control patients who did not have tibial loosening. There were two independent reviewers who then measured the thickness of the cement interface in 10 locations along the bone-implant interface from initial postoperative radiographs. The averages of the reviewers' measurements were calculated and then compared using independent t-tests.

RESULTS

Aseptic tibial loosening cases involving implant A tibial baseplate (n = 75) had significantly thinner cement interfaces than matched controls at all the 10 locations measured. Aseptic loosening cases involving implant B (n = 17) also displayed a thinner cement interface than matched controls in all locations, but this result was only statistically significant at the medial baseplate, medial keel, lateral keel, anterior keel, and posterior baseplate.

CONCLUSIONS

In two widely used TKA systems, tibial aseptic loosening was associated with significantly thinner cement interfaces when compared to propensity-matched controls in two different implant types. Further prospective studies are needed to identify the optimal keel preparation and design as well as minimal cement interface thickness to avoid implant loosening.

LEVEL OF EVIDENCE

III.

Preventive strategies to reduce the rate of periprosthetic infections in total joint arthroplasty; a comprehensive review

The increasing frequency of total hip (THA) and knee arthroplasties (TKA) is marred by the rise in periprosthetic joint infections (PJIs) and surgical site infections (SSIs), with PJIs incurring costs over $1.62 billion as of 2020 and individual case management averaging $90,000. SSIs additionally burden the U.S. healthcare economy with billions in expenses annually. PJI prevalence in primary THA and TKA ranges from 0.5% to 2.4%, spiking to 20% in revisions and representing 25% of TKA revision causes. Projections estimate up to 270,000 annual PJI cases by 2030. Often caused by gram-positive bacteria, particularly methicillin-resistant staphylococci, these infections demand preventive measures. This review dissects PJI prevention across preoperative, intraoperative, and perioperative phases, aligning with evidence-based CDC and WHO guidelines. Preoperative measures include managing diabetes, obesity, tobacco use, Staphylococcus aureus screening and nasal decolonization, nutritional optimization, and management of inflammatory arthropathies. Intraoperatively, antibiotic prophylaxis, skin preparation, operative room environmental controls, surgical technique precision, and irrigation options are scrutinized. Perioperative concerns focus on anticoagulation, blood management, and infection risk mitigation. Integrating these strategies promotes a patient-centric care model, aiming to reduce PJI incidence, improve patient outcomes, and increase care cost-effectiveness in joint arthroplasty.

Pulsed lavage is associated with better quality of bone-cement-implant interface in knee arthroplasties (TKA/UKA) compared to syringe lavage in vitro; however, clinical data are missing: A systematic review

Purpose

The purpose of this systematic review is to analyse the available literature to ascertain the optimal method of bone preparation to improve the quality of bone-cement-implant interface with either pulsed lavage or syringe lavage in both total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA).

Methods

A comprehensive search was conducted across MEDLINE, Scopus and Embase databases until July 2023. Both inclusion and exclusion criteria were clearly stated and used to identify all the published studies. Subsequent screening throughout the title, abstract and full text was made, followed by complete critical appraisal and data extraction. This sequential process was performed by two reviewers independently and summarised following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines). A quality assessment of the systematic review was performed according to the Quality Appraisal for Cadaveric Studies scale (QUACS), reaching a quality level ranging from 69% to 85%.

Results

A total of 10 articles, out of 47, nine biomechanical cadaveric studies and one human clinical study were analysed. A total of 196 UKA tibial components, 74 patellar components, 36 TKA tibial components and 24 UKA femoral components were retrieved, and a high level of heterogeneity resulted overall. The pulsed lavage group showed better cement penetration and higher pull-out force than the syringe lavage group; a higher interface temperature was also found in the pulsed lavage group. No differences were found regarding tension ligament forces between the groups.

Conclusion

Our systematic review suggests that pulsed lavage is superior to syringe lavage in terms of the quality of bone-cement-implant interface in knee arthroplasties (TKA/UKA). However, translation of these results from cadaveric studies to individual clinical settings may be hazardous; therefore, clinical in vivo prospective studies are highly needed.

PROSPERO CRD

PROSPERO CRD number CRD42023432399.

Level of Evidence

Level III.

Pulsatile lavage systems and their potential to penetrate soft tissue

BACKGROUND

In orthopedic and trauma surgery, pulsatile lavage systems are used to clean soft tissue. This may be necessary in septic surgeries or in case of contaminated wounds after trauma. Positive features such as reduction of bacterial contamination and removal of foreign particles are counterbalanced by negative aspects such as bacterial seeding in deeper tissue layers, damage to various tissues and even cases of air embolism.

PURPOSE

The aim of this prospective experimental in vitro study was to compare impact pressure and flow rate in three different pulsatile lavage systems and to determine, whether these parameters alter their ability to reach deeper soft tissue layers.

METHODS

To test the penetration of soft tissue, the muscle tissue was flushed with contrast medium instead of saline fluid and afterwards scanned by computed tomography.

RESULTS

Impact pressure and flow rate showed significant differences between the different systems. There were no significant differences between the three devices in terms of total penetration volume, but there were significant differences in penetration depth.

CONCLUSION

In this study, we found that higher impact pressure leads to deeper penetration and therefore bacteria are likely to be transferred to deeper tissue layers.

Pulsatile Lavage During Cementation of Total Knee Arthroplasty - Is Fixation Impaired? A Cadaver Study

BACKGROUND/AIM

Increasing economic pressure in modern healthcare necessitates an increase in efficiency in total knee arthroplasty (TKA) while maintaining high-quality outcomes. Removal of debris using pulsatile lavage (PL) during cement polymerization may considerably reduce the operative duration. However, water can penetrate the interface, resulting in impaired implant fixation. The aim of the present study was to investigate the impact of early-onset PL during bone cement polymerization on implant fixation and operative duration.

MATERIALS AND METHODS

Cemented implantation of tibial trays was performed in 20 fresh-frozen human tibiae from 10 donors in a matched-pair study design in two groups: 1) PL during cement polymerization; and 2) PL after completion of the polymerization process. The cement penetration depth was analysed by computed tomography (CT), and the pull-out force was measured to evaluate primary implant fixation. The duration of the procedure was recorded for both groups.

RESULTS

Comparable pull-out forces were observed in the experimental (2,213 N) and control groups (2,350 N; p=0.68). The mean depth of cement penetration was similar in both groups. PL during cement polymerization could decrease the operative duration by 10 min.

CONCLUSION

The application of PL during cement polymerization could significantly reduce operative duration and had no adverse effect on the mechanical fixation of the tibial component.

Pulsatile Lavage Systems with High Impact Pressure and High Flow Produce Cleaner Cancellous Bone Prior to Cementation in Cemented Arthroplasty

In cemented joint arthroplasty, state-of-the-art cementing techniques include high-pressure pulsatile saline lavage prior to cementation. Even with its outstanding importance in cementation, there are surprisingly few studies regarding the physical parameters that define pulsatile lavage systems. To investigate the parameters of impact pressure, flow rate, frequency and the cleaning effect in cancellous bone, we established a standardized laboratory model. Standardized fat-filled carbon foam specimens representing human cancellous bone were cleaned with three different high-pressure pulsatile lavage systems. Via CT scans before and after cleaning, the cleaning effect was evaluated. All systems showed a cleaning depth of at least 3.0 mm and therefore can be generally recommended to clean cancellous bone in cemented joint arthroplasty. When comparing the three lavage systems, the study showed significant differences regarding cleaning depths and volume, with one system being superior to its peer systems. Regarding the physical parameters, high impact pressure in combination with high flow rate and longer distance to the flushed object seems to be the best combination to improve the cleaning of cancellous bone and therefore increase the chances of a deeper cement penetration that is required in cemented joint arthroplasty. In summary, this study provides the first standardized comparison of different lavage systems and thus gives initial guidance on how to optimally prepare cancellous bone for cemented joint arthroplasty.

Does Additive Pressurized Carbon Dioxide Lavage Improve Cement Penetration and Bond Strength in Cemented Arthroplasty?

The modern cementing technique in cemented arthroplasty is a highly standardized and, therefore, safe procedure. Nevertheless, aseptic loosening is still the main reason for revision after cemented total knee or cemented total hip arthroplasty. To investigate whether an additional carbon dioxide lavage after a high-pressure pulsatile saline lavage has a positive effect on the bone-cement interface or cement penetration, we set up a standardized laboratory experiment with 28 human femoral heads. After a standardized cleaning procedure, the test implants were cemented onto the cancellous bone. Subsequently, the maximum failure load of the bone-cement interface was determined using a material testing machine to pull off the implant, and the cement penetration was determined using computed tomography. Neither the maximum failure load nor cement penetration into the cancellous bone revealed significant differences between the groups. In conclusion, according to our experiments, the additive use of the carbon dioxide lavage after the high-pressure pulsatile lavage has no additional benefit for the cleaning of the cancellous bone and, therefore, cannot be recommended without restrictions.

Pulsed lavage cleansing of osteochondral grafts depends on lavage duration, flow intensity, and graft storage condition

Introduction

Osteochondral allograft (OCA) transplantation is generally effective for treating large cartilage lesions. Cleansing OCA subchondral bone to remove donor marrow elements is typically performed with pulsed lavage. However, the effects of clinical and experimental parameters on OCA marrow removal by pulsed lavage are unknown. The aim of the current study was to determine the effects on marrow cleansing in human osteochondral cores (OCs) of (1) lavage duration, (2) lavage flow intensity, and (3) OC sample type and storage condition.

Methods

OCs were harvested from human femoral condyles and prepared to a clinical geometry (cylinder, diameter = 20 mm). The OCs were from discarded remnants of Allograft tissues (OCA) or osteoarthritis patients undergoing Total Knee Replacement (OCT). The experimental groups subjected to standard flow lavage for 45 seconds (430 mL of fluid) and 120 seconds (1,150 mL) were (1) OCT/FROZEN (stored at -80°C), (2) OCT/FRESH (stored at 4°C), and (3) OCA/FRESH. The OCA/FRESH group was subsequently lavaged at high flow for 45 seconds (660 mL) and 120 seconds (1,750 mL). Marrow cleansing was assessed grossly and by micro-computed tomography (μCT).

Results

Gross and μCT images indicated that marrow cleansing progressed from the OC base toward the cartilage. Empty marrow volume fraction (EMa.V/Ma.V) increased between 0, 45, and 120 seconds of standard flow lavage, and varied between groups, being higher after FROZEN storage (86–92% after 45–120 seconds) than FRESH storage of either OCT or OCA samples (36% and 55% after 45 and 120 seconds, respectively). With a subsequent 120 seconds of high flow lavage, EMa.V/Ma.V of OCA/FRESH samples increased from 61% to 78%.

Conclusions

The spatial and temporal pattern of marrow space clearance was consistent with gradual fluid-induced extrusion of marrow components. Pulsed lavage of OCAs with consistent time and flow intensity will help standardize marrow cleansing and may improve clinical outcomes.

Effect of lavage and brush preparation on cement penetration and primary stability in tibial unicompartmental total knee arthroplasty: An experimental cadaver study

BACKGROUND

Unicompartmental total knee arthroplasty (UKA) is a well-established treatment option for unicondylar osteoarthritis, and generally leads to better functional results than tricompartimental total knee arthroplasty (TKA). However, revision rates of UKAs are reported as being higher; a major reason for this is aseptic loosening of the tibial component due to implant-cement-bone interface fatigue. The objective of this study was to determine the effects of trabecular bone preparation, prior to implantation of tibial UKAs, on morphological and biomechanical outcomes in a cadaver study.

METHODS

Cemented UKAs were performed in 18 human cadaver knees after the bone bed was cleaned using pulsed lavage (Group A), conventional brush (Group B) or no cleaning at all (Group C, control). Morphologic cement penetration and primary stability were measured.

RESULTS

The area proportion under the tibial component without visible cement penetration was significantly higher in Group C (21.9%, SD 11.9) than in both Group A (7.1%, SD 5.8), and Group B (6.5%, SD 4.2) (P=0.007). The overall cement penetration depth did not differ between groups. However, in the posterior part, cement penetration depth was significantly higher in Group B (1.9mm, SD 0.3) than in both Group A (1.3mm, SD 0.3) and Group C (1.4mm, SD 0.3) (P=0.015). The mode of preparation did not show a substantial effect on primary stability tested under dynamic compression-shear test conditions (P=0.910).

CONCLUSION

Bone preparation significantly enhances cement interdigitation. The application of a brush shows similar results compared with the application of pulsed lavage.

The management of periprosthetic infections in the future: a review of new forms of treatment

The number of arthroplasties being undertaken is expected to grow year on year, and periprosthetic joint infections will be an increasing socioeconomic burden. The challenge to prevent and eradicate these infections has resulted in the emergence of several new strategies, which are discussed in this review. Cite this article: Bone Joint J 2015;97-B:1162-9.

The protective effect of pulsed lavage against implant subsidence and micromotion for cemented tibial unicompartmental knee components: an experimental cadaver study

Cemented UKAs were performed in 12 pairs of human cadaver legs and the bone bed was cleansed using pulsed lavage (group A) and conventional syringe lavage (group B). Subsidence and micromotion of the loaded tibial trays were measured. There was a significant effect of BMD on subsidence (P = 0.043) but not on micromotion. Cement penetration of group A was significantly increased (P = 0.005). Group A showed a reduced implant subsidence (P = 0.025) and micromotion (P = 0.026) compared to group B. The group differences in micromotion and implant subsidence of UKA tibial components were statistically significant but rather small and might clinically be of minor importance. Nevertheless a worse bone quality adversely affected implant subsidence and pulsed lavage had a protective effect in these specimens.

The effect of bone lavage on femoral cement penetration and interface temperature during Oxford unicompartmental knee arthroplasty with cement

BACKGROUND

Aseptic loosening is the most common cause for revision unicompartmental knee arthroplasty and is associated with failure of the bone-cement or cement-implant interface. The purpose of the present study was to analyze different bone lavage techniques for the bone-cement and cement-implant interfaces of the femoral component and to study the effect of these techniques on cement penetration and on interface temperature.

METHODS

In an experimental cadaver study, Oxford unicompartmental knee arthroplasty was performed in twenty-four matched-paired knees to study the effect of pulsed lavage compared with syringe lavage on femoral cement penetration and interface temperature. Interface temperature, cement penetration pressure, and ligament tension forces were measured continuously during the procedure, and cement penetration was determined by performing sagittal bone cuts.

RESULTS

Cleansing the femoral bone stock with use of pulsed lavage (Group B) led to increased femoral cement penetration (mean, 1428 mm²; 95% confidence interval, 1348 to 1508 mm²) compared with syringe lavage (Group A) (mean, 1128 mm²; 95% confidence interval, 1038 to 1219 mm²) (p < 0.001). Interface temperature was higher in Group B (mean 22.6°C; 95% confidence interval, 20.5°C to 24.1°C) than in Group A (mean, 21.0°C; 95% confidence interval, 19.4°C to 23.0°C) (p = 0.028), but temperatures never reached critical values for thermal damage to the bone.

CONCLUSIONS

Pulsed lavage leads to an increased femoral cement penetration without the risk of heat necrosis at the bone-cement interface.

Bone-cement interface strength in distal radii using two medullary canal preparation techniques: carbon dioxide jet cleaning versus syringed saline

PURPOSE

Loosening is an important cause of failure of upper limb arthroplasty and improvement in cementation techniques may limit this. The currently accepted medullary canal preparation techniques use saline washing and gauze drying. Another method of bone preparation uses carbon dioxide compression gas jet which blows debris from the canal, whilst simultaneously drying the bone. We compared the push out strengths of cement plugs in sections of human cadaveric radii that had been prepared using either syringed saline or carbon dioxide jet cleaning.

METHODS

Following bone preparation, four radii in each group, were cemented in a standardised fashion, and cut into 1 cm sections. An Instron materials testing machine was used to measure the force needed to push the cement plug out of the bone section.

RESULTS

The force needed to push out the cement plug was significantly higher in the carbon dioxide jet (median 580.61, IQR 429.10-650.05) as compared to the saline group (median 366.57N, IQR 271.05-502.23), P = 0.009. The mechanism of failure of the bone-cement interface also differed between the two groups, with 100% of the sectioned cortices fracturing prior to cement extrusion in the carbon dioxide jet group, but only 23% of the sectioned cortices doing so in the saline group.

CONCLUSION

Our results suggest that there is a statistically stronger macro-interlock at the bone-cement interface after preparation of the medullary canals of radii using a carbon dioxide compression gas jet as compared to saline irrigation.

Pulsed lavage improves fixation strength of cemented tibial components

Pulsatile lavage is purported to improve radiographic survival in cemented total knee arthroplasty (TKA). Similarly, a potential improvement of fixation strength of the tibial tray has been assumed based on the increased cement penetration. In this study, the influence of pulsed lavage on fixation strength of the tibial component and bone cement penetration was evaluated in six pairs of cadaveric specimens. Following surgical preparation, the tibial surface was irrigated using pulsatile lavage on one side of a pair, while on the other side syringe lavage was applied. All tibial components were implanted using the same cementing technique. Cement penetration and bone mineral density was assessed based on computed tomography data. Fixation strength of the tibial trays was determined by a pull-out test with a material testing machine. Median pull-out forces and cement penetration were significantly (p = 0.031) improved in the pulsed lavage group as compared to the syringe lavage group. Enhanced fixation strength is suggested as being a key to improved survival of the implant. Consequently, pulsatile lavage should be considered as a mandatory preparation step when cementing tibial components in TKA.

Cementing technique in femoral resurfacing

INTRODUCTION

The cementing technique is one of the various speculated factors that might contribute to the failures of resurfacing arthroplasty of the hip. The influence of bony preparation by jet lavage or lavage only in combination with different cementing techniques and cements of different viscosity in a study on fresh human femoral heads has not been evaluated so far.

MATERIALS AND METHODS

Sixty fresh human femoral heads were prepared for resurfacing following manufacturers' instructions and divided into 12 groups. The different groups received either syringe lavage or jet lavage and either a low-, medium- or high-viscosity cement with either packing or quarter filling of the implant with recess of the femoral stem in each case. Application of the implant was standardized. After polymerization, the femoral heads were cut into quarters and polished. Cement penetration was assessed using a square millimeter grid under optical zoom.

RESULTS

Manual packing with high viscosity cement is a reproducible method in resurfacing arthroplasty. Syringe lavage and jet lavage mainly showed comparable cement penetration patterns when applied same cementing techniques. The penetration depth ranged from a mean of 0.6 to 3.2 mm with 0.4 being the lowest and 4.0 being the deepest. The mantle thickness ranged from 0.8 to 2.4 mm with statistically significant thicker mantles with filling, compared to packing.

CONCLUSION

Our results showed distinct less penetration depth than previously reported and that just medium viscosity cement reached reliable results in the supposed range of penetration depth and cement mantle thickness. Jet lavage should be recommended for the low-viscosity cement but avoided in combination with a cement filling technique of lower viscosity cements. Filling of the implant caused the greatest penetration depth and a higher number of incomplete seatings and should therefore be avoided.