Pulsatile Lavage of Musculoskeletal Wounds Causes Muscle Necrosis and Dystrophic Calcification in a Rat Model

Abstract

Background: Adequate irrigation of open musculoskeletal injuries is considered the standard of care to decrease bacterial load and other contaminants. While the benefit of debris removal compared with the risk of further seeding by high-pressure lavage has been studied, the effects of irrigation on muscle have been infrequently reported. Our aim in the present study was to assess relative damage to muscle by pulsatile lavage compared with bulb-syringe irrigation. Methods: In an animal model of heterotopic ossification, 24 Sprague-Dawley rats underwent hindlimb blast amputation via detonation of a submerged explosive, with subsequent through-the-knee surgical amputation proximal to the zone of injury. All wounds were irrigated and underwent primary closure. In 12 of the animals, pulsatile lavage (20 psi [138 kPa]) was used as the irrigation method, and in the other 12 animals, bulb-syringe irrigation was performed. A third group of 6 rats did not undergo the blast procedure but instead underwent surgical incision into the left thigh muscle followed by pulsatile lavage. Serial radiographs of the animals were made to monitor the formation of soft-tissue radiopaque lesions until euthanasia at 6 months. Image-guided muscle biopsies were performed at 8 weeks and 6 months (at euthanasia) on representative animals from each group. Histological analysis was performed with hematoxylin and eosin, alizarin red, and von Kossa staining on interval biopsy and postmortem specimens. Results: All animals managed with pulsatile lavage, with or without blast injury, developed soft-tissue radiopaque lesions, whereas no animal that had bulb-syringe irrigation developed these lesions (p = 0.001). Five of the 12 animals that underwent blast amputation with pulsatile lavage experienced wound complications, whereas no animal in the other 2 groups experienced wound complications (p = 0.014). Radiopaque lesions appeared approximately 10 days postoperatively, increased in density until approximately 16 weeks, then demonstrated signs of variable regression. Histological analysis of interval biopsy and postmortem specimens demonstrated tissue damage with inflammatory cells, cell death, and dystrophic calcification. Conclusions: Pulsatile lavage of musculoskeletal wounds can cause irreversible insult to tissue, resulting in myonecrosis and dystrophic calcification. Clinical Relevance: The benefits and offsetting harm of pulsatile lavage (20 psi) should be considered before its routine use in the management of musculoskeletal wounds.

Pulsatile lavage systems and their potential to penetrate soft tissue

“…Pulsatile lavage can reduce bacterial contamination of different surfaces and different wounds [7][8][9]. Although it is more effective than bulb syringe alone [12,13], research found that it can result in irreversible tissue damage [15,21,22].…”

“…Recent examinations showed that high-pressure pulsatile lavage propagates bacteria into soft tissue [ 20 ], but there is no data showing that depth of penetration and more bacteria in deeper soft tissue layers lead to higher infection rates. It has also been shown that pulsatile lavage of musculoskeletal wounds at a pressure of 0.14 N/mm 2 can lead to irreversible tissue damage, resulting in myonecrosis and dystrophic calcification in a rat model [ 21 ]. Boyd et al also proved that high-pressure pulsatile lavage causes soft tissue damage [ 22 , 23 ].…”

Does Pressurized Carbon Dioxide Lavage Improve Bone Cleaning in Cemented Arthroplasty?

“…Since we saw similar results for single use carbon dioxide lavage (Group B) compared to single use of pulsatile lavage (Group A) it has to be considered, that using carbon dioxide lavage only, might be faster, less wet and more controlled to saline lavage. Studies showed that using high-pressure lavage to clean contaminated wounds can cause irreversible insult to tissue, resulting in myonecrosis and dystrophic calcification [43,44]. Even bacteria can be propagated into soft tissue or significant damage to the architecture of the bone can occur [45,46].…”

Progressive brachial plexopathy secondary to heterotopic ossification formation after shoulder trauma: a case report

“…2 It is important to distinguish HO from metastatic calcifications and dystrophic calcification in necrotic tissue or tumors. 7 While these calcifications may share some radiographic features with HO, the pathophysiological causes are separate from HO. 1,7 Most current research into HO focuses on understanding the underlying physiological and mechanical processes that cause HO development, designing better diagnostic strategies, and developing improved preventative and therapeutic measures.…”

“…7 While these calcifications may share some radiographic features with HO, the pathophysiological causes are separate from HO. 1,7 Most current research into HO focuses on understanding the underlying physiological and mechanical processes that cause HO development, designing better diagnostic strategies, and developing improved preventative and therapeutic measures. 3,6 The authors report on a patient with post-traumatic HO encasing the axillary vessels and the infraclavicular brachial plexus.…”