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

Abstract

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.

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

“…Achieving optimal cement penetration is of pivotal importance to ensure satisfactory bony interdigitation culminating in a strong prosthetic bone–cement interface [ 19 , 25 , 31 , 33 ]. There is still ambiguity with regard to what constitutes optimal cement penetration, but it is generally agreed that 3–5 mm of penetration depth provides adequate stability, while penetration of 1.5 mm or less is associated with aseptic radiolucency and risk of subsequent loosening [ 15 , 25 , 31 ].…”

“…Conceivably, there is still no consensus on the optimal method of bone surface preparation, neither is there any evidence to demonstrate which lavage technique gives a salubrious bone bed for optimal cement penetration and interlocking with cancellous bone. Although high‐impact pressure and high‐flow pulsatile lavage was demonstrated to improve cement penetration and stability of components in an experimental study [ 15 ], it remains to be seen whether it offers additional advantages compared to traditional syringe lavage, which would justify the additional cost for routinely using pulsed lavage for knee arthroplasty in highly competitive health care environment. This conundrum is evident in the fact that data from a survey shows the prevalence of pulsed lavage use not exceeding 70% for lower limb arthroplasties [ 17 ].…”

Pulsatile lavage systems and their potential to penetrate soft tissue

“…Then, the areas were marked and calculated with ImageJ [ 24 ]. The maximum impact pressure was calculated during an already established 30 min test [ 25 ]. Maximum impact pressure was evaluated at 0.5, 5, 10, 15, 20, 25 and 30 min.…”