Pulsed lavage improves fixation strength of cemented tibial components

Abstract

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.

Loss of Cement-bone Interlock in Retrieved Tibial Components from Total Knee Arthroplasties

“…Additional penetration beyond 5 mm is thought to increase the risk of thermal necrosis [2]. Use of pulsatile lavage and pressurization of cement has been shown to reduce the initial occurrence of radiolucent lines at the cement-bone interface [17] and increase the amount of cement penetration into the trabecular bone bed [18]. In cases where there is sclerotic bone, drilling the cut surface has been advocated to allow penetration of the cement [2].…”

An in vitro comparison of tibial tray cementation using gun pressurization or pulsed lavage

“…There is evidence that thorough surface preparation using PL improves bone cement penetration and thus, initial fixation strength, in TKA [5,14,19]. In a German survey investigating cementing techniques in THA, only 66.5 % of respondents used PL as a standard procedure [6].…”

“…Osseous abnormalities were ruled out, and bone mineral density (BMD) was assessed in the proximal region near the tibial surface using a normal calibration (Mx8000, Philips, Best, The Netherlands). Analysis is described in detail elsewhere [19]. In all cases, PFC Sigma® MBT Keeled tibial components were implanted (PFC Sigma® Knee System, DePuy Orthopaedics, Warsaw, IN, USA).…”

“…However, concerns remain that the technique could lead to overpenetration of cement, with subsequent thermal damage to the cancellous bone [9]. Pulsed lavage (PL) significantly improved interface strength and cement penetration compared wtih syringe lavage (SL) in a cadaveric investigation [19]. A survey of cementing techniques in TKA revealed that only 68 % of surgeons questioned routinely used PL [12].…”

Comparison of different cement application techniques for tibial component fixation in TKA

“…The specific cementing technique for tibial trays remains debated [5]. Initial fixation strength can be more than doubled by using pulsed lavage [39]. There is little consensus regarding other aspects; some surgeons recommend cementing the stem of the component, while others prefer a surface cementation approach [16,34].…”