Pulsatile Lavage Research Articles

Traumatic Wound Debridement

To test wound debridement efficacy and soft tissue damage produced by high-pressure pulsatile lavage (HPPL), suction irrigation, and bulb syringe irrigation. Randomized trial in an in vitro model. Medical school orthopaedic department. No patients were used in this study. Beef flank steaks (100-g +/- 10-g) were divided into 8 test groups and incised uniformly. Four test groups were contaminated with 2 g of rock dust and 4 were not. The specimens were then treated as follows: nothing (control), bulb irrigation, suction irrigation, or HPPL. Runoff from the irrigation was collected, filtered, lyophilized, and ashed to allow for quantitative determination of organic and inorganic material removed from the wound by each irrigation method. Digital photographs of the tissue samples were subjected to blinded grading on a scale of 1 to 5 to assess macroscopic soft tissue damage. Qualitatively, tissue samples treated with HPPL consistently received worse grades for tissue damage than samples in any other experimental group. Quantitative soft tissue damage analysis revealed that significantly more organic material was removed from samples treated with HPPL (141.3 +/- 58.9 mg) than those treated with bulb syringe (50.7 +/- 28.6 mg) or suction irrigation (108.7 +/- 174.5 mg). Surprisingly, significantly less inorganic contaminant was removed from tissue samples treated with HPPL (1549.6 +/- 77.3 mg) than those treated with bulb syringe (1834.9 +/- 39.1 mg) or suction irrigation (1827 +/- 39.4 mg). There has been some concern regarding damage produced by HPPL. According to our quantitative soft tissue damage data, tissue treated by HPPL was damaged significantly more than tissue treated with bulb syringe or suction irrigation. Our qualitative tissue damage grade data showed that HPPL treated test groups appeared more damaged than other irrigation groups. Surprisingly, HPPL removed significantly less inorganic contaminant than other debridement methods, and it is proposed that HPPL may drive some contaminants deeper into the tissue rather than removing them. This study seems to support the concept that suction and sharp debridement, as practiced by most surgeons, may remove foreign bodies well without the use of HPPL.

High-Pressure Pulsatile Lavage Propagates Bacteria into Soft Tissue

Initial wound treatment is critical in the treatment of open fractures, contaminated wounds, and abscesses. Ample evidence suggests that high-pressure pulsatile lavage damages bone structure and disrupts soft tissue. We compared the depth of penetration and amount of retention of bacteria in contaminated soft tissue subjected to one of two lavage methods: high-pressure pulsatile and low-pressure gravity flow. Fresh ovine muscle was harvested, contaminated with fluorescently stained Staphylococcus aureus, and subjected to lavage treatment. Specimens in each lavage method group were subdivided based on orientation across or in line with the muscle fibers. High-pressure lavage causes increased depth of bacterial penetration (across: 3,835 microm; in line: 4,220 microm) when compared with low-pressure lavage (across: 1,680 microm; in line: 2,095 microm). Furthermore, both high-pressure treatment groups had higher numbers of retained bacteria as counted in 50 mum x 7,500 microm x 5 microm sections of tissue after lavage (across: 197; in line: 188) when compared with the low-pressure groups (across: 94; in line: 40). These results show that high-pressure pulsatile lavage causes deeper penetration of bacteria and results in greater bacterial retention in soft tissue when compared with low-pressure lavage.

Poster 193: Pulsatile Lavage as an Adjunct Hydrotherapy Treatment for Pressure Ulcers: A Randomized Controlled Trial

Objective: To test the hypothesis that pulsatile lavage as an adjunct hydrotherapy will enhance the healing rate of stage III or IV pressure ulcers in persons with spinal cord injury (SCI). Design: Randomized, controlled, double-blind study. Setting: Tertiary care SCI inpatient unit. Participants:20 SCI subjects were randomly assigned to pulsatile lavage treatment group (n=10) or sham treatment group (n=10). All had stage III or IV pelvic pressure ulcers with minimum dimension of 3cm and maximum dimension of 15cm (in length, width or depth).

Prevention of Aerosol Contamination During Pulsatile Lavage

Prevention of Aerosol Contamination During Pulsatile Lavage

Zementierte Hüftendoprothetik in Deutschland - ein Update

The results of a national survey from 1998 had shown at the time that only around 10 % of orthopaedic surgeons in Germany had strictly implemented modern cementing techniques in total hip arthroplasty (THA). The same study was repeated 5 years later to evaluate the current situation and to determine whether modern cementing techniques have become more popular. A detailed, slightly modified questionnaire regarding cement and bone preparation, cementing techniques on acetabulum and femur, and implant types was sent to 572 German orthopaedic and trauma hospitals, as well as to visiting surgeons with an interest in THA. In total, 293 questionnaires were available for evaluation and statistical analysis. Palacos bone cement remained the most widely used cement (> 90 %). The mixing times given varied significantly. Vacuum mixing systems had become more popular (67.9 %). In the femur 81.8 % of the surgeons attempted to preserve cancellous bone and 57.2 % used pulsatile lavage (jet-lavage). Retrograde cement application via a cement gun was done in 71.1 %. Cement restrictors were used in more than 95 %. Only two-thirds of the surgeons implemented sustained cement pressurisation and preferred a cement mantle thickness > 2mm (64 %). Only 16.9 % made multiple small acetabular keyholes and 48.6 % used jet-lavage. In 73.1 % no cement gun was used and in 68.3 % the cement was applied at high viscosity. Manual cement pressurisation was done in 58.1 %. The Muller straight stem device remained the most popular implant. For only 5 of the over 50 stem designs implanted have long-term results been published as yet. Only 10.6 % of surgeons/centres performed > 20 and almost 50 % implanted > 100 cemented THAs/year. The results of this survey demonstrated that, in comparison to 1998, the current state of cemented THA, in particular cementing technique has significantly improved. Future emphasis should be on continued surgeon education and training, as the operative, i. e., cementing techniques are of utmost importance for long-term success.

An Outbreak of Multidrug-Resistant <EMPH TYPE="ITAL">Acinetobacter baumannii</EMPH> Associated With Pulsatile Lavage Wound Treatment

Pulsatile lavage is a high-pressure irrigation treatment used increasingly in a variety of health care settings to debride wounds. Infection control precautions are not routinely used during the procedure and are not included in pulsatile lavage equipment package labeling. To investigate an outbreak of multidrug-resistant Acinetobacter baumannii and to test the hypothesis that pulsatile lavage wound treatment was the mode of transmission for the organism. Outbreak case-control investigation including case identification, review of medical records, environmental cultures, and pulsed-field gel electrophoresis. A 1000-bed tertiary care hospital in Baltimore, Md, during September and October 2003. The investigation included 11 patients infected or colonized with multidrug-resistant A baumannii. Seven of these patients met the case definition for the case-control study and were compared with 28 controls randomly selected from a list of inpatients without multidrug-resistant A baumannii who had a wound care consultation. Infection or colonization with multidrug-resistant A baumannii. Eleven patients had cultures that grew multidrug-resistant A baumannii during the outbreak period. Of the 10 health care-associated cases, 8 had received pulsatile lavage treatment. One strain of multidrug-resistant A baumannii was recovered from all 6 pulsatile lavage patients who had isolates available for pulsed-field gel electrophoresis analysis and from multiple surfaces in the wound care area. Six of 7 cases (86%) were treated with pulsatile lavage vs 4 of 28 controls (14%) (odds ratio, 36; 95% confidence interval, 2.8-1721; P<.001). These results confirm that pulsatile lavage was a significant risk factor for acquisition of multidrug-resistant A baumannii. Transmission was apparently caused by dissemination of multidrug-resistant A baumannii during the pulsatile lavage procedure, resulting in environmental contamination. Appropriate infection control precautions should be used during pulsatile lavage therapy and should be included in pulsatile lavage equipment labeling.

High-Pressure Pulsatile Lavage Causes Soft Tissue Damage

Irrigation and debridement can be a source of iatrogenic injury in open fracture treatment. Although high-pressure pulsatile lavage has been shown to cause considerable damage to bone, little has been written about its effects on soft tissue. The purpose of this study is to quantify and compare the damages on soft tissue caused by high-pressure pulsatile lavage and low-pressure lavage. Forty specimens of fresh ovine muscle were collected and subjected to high-pressure pulsatile lavage or low-pressure lavage, with the delivery orientation being across or in line with the muscle fibers. Ten additional specimens were used as controls. The results show that high-pressure pulsatile lavage causes considerable soft tissue penetration of particulate markers (across, 4.7 mm; in line, 15.6 mm) when compared with low-pressure lavage (across, 0.5 mm; in line, 0.7 mm). Furthermore, all specimens subjected to high-pressure pulsatile lavage showed gross tissue disruption. Fifteen additional samples were obtained to measure cellular death. This was observed at a deeper level for high-pressure pulsatile lavage (median depths: across, 1210 microm; in line, 1335 microm), which was approximately twice that of low-pressure lavage (across, 485 microm; in line, 682 microm). These results show that high-pressure pulsatile lavage penetrates and disrupts soft tissue to a deeper level than low-pressure lavage, causing considerable gross and microscopic tissue disruption.

Outbreak of Multiantimicrobial-Resistant Acinetobacter baumannii Related to Pulsatile Lavage

ISSUE: We investigated an outbreak of multiantimicrobial-resistant Acinetobacter baumannii (MDR-AB) in a 1000-bed hospital. A. baumannii survives on surfaces for extended time periods and colonizes or infects the respiratory tract and wounds. PROJECT: In October 2003, 12 patients had MDR-AB cultured from wounds. Cases were patients with cultures (CX) growing MDR-AB. MDR-AB were resistant to all antibiotics except colistin. Strict contact isolation was implemented. Sign-in was required for entry into patient pt rooms to track potential exposures. Record review revealed that all case patients underwent wound care with Pulsatile Lavage (PL), which is a pressurized wound flush device. The procedure was observed, environmental CX were collected in the treatment area and all patients who underwent PL were identified. CX of the PL environment grew MDR-AB. The treatment area was closed and thoroughly cleaned. Staff was instructed on proper infection control. Surveillance CX of all patients treated with PL was obtained from the time the index case was identified. Pulsed-field gel electrophoresis revealed that 6 patients who received PL had identical strains, which were also identical to environmental CX. We hypothesized the organism was aerosolized during PL therapy based on 1) environmental contamination matching the outbreak strain, and 2) infected patients. RESULTS: The outbreak resolved after all CX-positive patients were identified and aggressive infection control measures were instituted. No new cases were identified after October 2003. LESSONS LEARNED: MDR-AB can be transmitted by aerosolization during PL. The FDA and CDC have worked to change the infection control procedures in the product labeling on the PL device.

A technique for reducing splash exposure during pulsatile lavage.

Pulsatile lavage is a frequently used method among orthopaedic traumatologists at our institution in the management of open fractures and contaminated wounds. Due to the pressure generated by the pulsatile lavage systems, splash exposure in the operating room environment becomes an unavoidable occurrence. The potential exists for a mucocutaneous exposure for either the surgeon or the operating room personnel. We have devised a method of decreasing the exposure risk to surgeons and operating room personnel during the pulsatile lavage irrigation portion of the procedure. An x-ray cassette drape is placed over the affected limb with enough clamps to create a closed system. Then small holes are created for the pulsatile lavage and the suction tubing, and the irrigation procedure is begun. This inexpensive cassette cover has proved to be a substantial advantage in our institution for decreasing mucocutaneous exposure.

Suction technique to improve cement penetration under the tibial component in total knee arthroplasty

Improving the longevity and reliability of cemented total knee arthroplasty remains an important part of orthopaedic research. This paper examines the recently described method of preparation of the cancellous surface of the tibia using suction cannulae in the proximal tibia and stem recess during pulsatile lavage and component fixation. The technique provides a surface clear of debris, fat, blood and marrow, and prevents backflow of blood. A retrospective analysis of post-operative radiographs shows significant improvement in the penetration of cement into the tibial plateau, and improved cement profile towards the periphery. Techniques of stem cementation are also compared, and it is recommended that for this particular design implant, cement should be applied into the cut stem recess in the tibia rather than to the stem of the implant itself. This technique of preparation of the cut surface of the tibia is a simple and, to-date, complication-free method of reliably providing satisfactory cement penetration during total knee arthroplasty.

The biomechanical effect of high-pressure irrigation on diaphyseal fracture healing in vivo.

To evaluate the effect of both high-pressure pulsatile lavage and bulb syringe irrigation on the biomechanical parameters of fracture healing using an in vivo open noncontaminated diaphyseal femoral fracture model in rats. The utility of high-pressure pulsatile lavage irrigation on soft tissue debridement has been extrapolated to a similar perceived benefit in the debridement of bone. However, there have been several reports of a possible deleterious effect that high-pressure pulsatile lavage may have on bone architecture, intramedullary bacterial and contaminant seeding, and fracture healing. Although a previous in vivo histologic study suggests damage to bone architecture and impairment of early bone formation, it remains unclear whether these microscopic findings translate to a detectable decline in the biomechanical strength of the healing fracture. To our knowledge, there have been no reports of the in vivo effects high-pressure pulsatile lavage on fracture healing in open diaphyseal fractures. Using sterile technique, standard open transverse mid-shaft femur fractures were created in thirty-six rats randomized into three groups: a control group underwent retrograde intramedullary pinning only; a bulb syringe irrigation group and a high-pressure pulsatile lavage group underwent identical procedures as the control group, except that the osteotomy site was irrigated with bulb syringe irrigation and high-pressure pulsatile lavage, respectively, before insertion of the intramedullary pin. Six rats from each group were killed at three weeks and six weeks, and the femora was mechanically tested in bending. Mechanical testing of the thirty-six femora revealed that the peak bending force (17.7 +/- 10.2 N) and stiffness (21.2 +/- 5.1 N/mm) of the healing fracture in the high-pressure irrigation group were significantly lower at three weeks when compared with the control (peak force, 28.1 +/- 5.9 N; stiffness, 31.4 +/- 5.8 N/mm) and the bulb syringe (peak force, 27.7 +/- 3.3 N; stiffness, 23.6 +/- 4.5 N/mm) irrigation groups (p < 0.05). The 37 percent lower peak bending force and 32 percent lower stiffness in the high-pressure pulsatile lavage group after three weeks of fracture healing were not present in the femora tested at six weeks. The high-pressure pulsatile lavage group did reveal a trend toward a lower peak bending force and stiffness after six weeks of fracture healing when compared with the control and bulb syringe irrigation groups, but the differences were not statistically significant at the 95 percent level. The use of high-pressure pulsatile lavage in open noncontaminated diaphyseal femur fractures in rats has a significant negative impact on the mechanical strength of the fracture callous during the early phases (three weeks) of fracture healing. However, it appears that the early deleterious effect of high-pressure pulsatile irrigation is not apparent in the late phases (six weeks) of fracture healing. Further study is required to evaluate the effect of high-pressure pulsatile lavage on fracture healing in the presence of wound contamination, fracture comminution, and soft tissue damage. The findings of this study suggest that selective use of high-pressure irrigation in the management of open fractures appears warranted. In situations in which high-pressure lavage may be deleterious to bone healing, alternative strategies that optimize bacterial removal from soft tissues while preserving bone architecture will need to be investigated.

High-pressure pulsatile lavage irrigation of contaminated fractures: effects on fracture healing

To evaluate the effects of high-pressure pulsatile lavage (HPPL) irrigation on new bone formation and fracture union in a contaminated intraarticular fracture, 45 New Zealand white rabbits were divided into three equal groups. The control group (C) underwent an osteotomy of the medial femoral condyle, contamination with a slurry of clay mixed with Staphylococcus aureus, stabilization and closure. The bulb syringe and pulsatile groups (B and P) underwent an identical procedure, with the addition of irrigation with 1 l of saline by bulb syringe or pulsatile lavage system. Two fluorescent bone stains that mark new bone formation were administered subcutaneously: xylenol orange at the time of surgery and calcein green one week postoperatively. Animals were euthanized two weeks postoperatively and femurs were retrieved for histological analysis. Union was determined by examination of microradiographs. The viability of bone along the osteotomy site in the first and second weeks after irrigation was determined by evaluation of the two fluorescent stains. The density of new bone two weeks after irrigation was assessed by digitization of the microradiographs. Nonunion was present in 77%, 53%, and 43% of animals in groups C, B, and P, respectively. There was an increase in the presence of bands of both fluorescent stains along the osteotomy site in the groups B and P compared to group C. There was no statistically significant difference between groups B and P in either fluorescent stain. On digitization of microradiographs, there was more calcified new bone on postoperative day 14 in group P than in either group B or C ( p=0.04). The addition of contamination and foreign material to an intraarticular fracture model results in lower rates of new bone formation and fracture union. Irrigation in this setting is clearly beneficial, whether the irrigant is delivered by bulb irrigation or by HPPL. The results of this study indicate using HPPL in this setting does not cause greater damage than using bulb syringe irrigation.

Influence of cement viscosity on cement interdigitation and venous fat content under in vivo conditions: a bilateral study of 13 sheep.

In a sheep model permitting standardized bilateral, simultaneous cement pressurization, we studied the effect of different cement viscosities on fat and bone marrow intravasation and cement penetration in vivo. High viscosity cement (Palacos) was used on one side and low viscosity cement (Osteopal) on the other. Catheters were inserted into both external iliac veins to collect blood during bilateral simultaneous cement pressurization. After bone preparation and pulsatile lavage, both femora were filled with cement followed by simultaneous cement pressurization. A quantitative fat analysis of the blood collected was done. We used microradiographs to determine cement penetration in a left versus right comparison of both viscosity groups. The low viscosity cement yielded lower rates of cement penetration despite adequate and sustained pressurization. Cement applied at low viscosity state seems to take the path of least resistance into the venous system before more deeper cement penetration can occur. The use of high viscosity cement ran a higher risk of fat embolism, but improved cement interdigitation.

Die Bedeutung der Jet-Lavage für das In-vitro- und In-vivo-Zementierergebnis

The purpose of this study was to determine the efficacy of pulsatile jet lavage and manual syringe lavage with regard to their cleansing capabilities as measured by cement penetration into cancellous bone both in vivo and in vitro. Three separate experiments were performed. Study A: In a cadaver study 36 left human cadaver femora were used for implantation of cemented femoral components. Conventional broaches were used for femoral preparation. Bone lavage was carried out either using jet lavage or manual syringe lavage of equal volume. The allocation to two different lavage groups was randomised. In both groups high-pressurising cementing techniques were implemented with the use of a proximal seal and additional finger packing. Study B: To guarantee standardised cement pressurisation and equal bone quality, the influence of jet lavage (1000 ml) versus syringe lavage (1000 ml) was studied in 11 paired human cadaver femora in an additional study without prosthesis implantation. The specimens were imbedded in specially designed pots. Bone cement was applied in a retrograde manner and subjected to a standard pressure protocol with a constant force of 3000 N. Study C: To directly compare the effectiveness of both pulsatile jet and syringe lavage with regard to cement penetration in vivo, a new sheep model allowing for standardised bilateral, simultaneous cement pressurisation was used. After femoral neck osteotomies both femoral cavities of 10 sheep were prepared for retrograde cement application. After randomisation one side was lavaged with 250 ml irrigation using a bladder syringe, the contralateral femur with the identical volume but using a pulsatile lavage. A specially designed apparatus was used to allow for bilateral simultaneous cement pressurisation. In all studies horizontal sections were obtained from the femoral specimens at predefined levels using a diamond saw. Microradiographs were taken and analysed using image analysis to assess cement penetration into cancellous bone. Study A: Compared with syringe lavage the use of jet lavage significantly improved the penetration of cement into cancellous bone (p = 0.027). In the presence of strong, dense cancellous bone the findings were more pronounced. Study B: Our results show that in equal quality bone, the use of jet lavage yields significantly (p < 0.001) improved cement penetration compared to syringe lavage specimens. Study C: The results of the in vivo study confirmed the superiority of jet lavage bone surface preparation (p = 0.002). The use of jet lavage yields significantly improved interdigitation between cancellous bone and cement both in vitro and in vivo and should be regarded as mandatory in cemented total hip arthroplasty. High pressurising techniques are effective means to improve cement penetration, but should only be administered with jet lavage to reduce the risk of fat embolism.

Thromboembolic complications related to the use of bone cement in hip arthroplasty--pathogenesis and prophylaxis

Cemented total hip arthroplasty (THA) has to be considered a high-risk procedure with respect to cardiovascular complications. The insertion of cement and prosthesis may lead to intravasation of fat and bone marrow into the circulation. This article represents a review on the relevant literature about thromboembolic complications associated with the use of bone cement in THA. The method of canal preparation and lavage is of paramount importance to reduce the potential embolic load. Additionally, thorough cleaning of the intramedullary cavity (using jet lavage) improves the cement penetration into the bone and increases the shear strength of the bone-cement interface. Modern cementing techniques include the use of high pulsatile lavage, a cement restrictor and cement pressurization. With the application of these techniques a sufficient drainage of the medullary canal should be guaranteed to minimise the risk for thromboembolic complications. During the insertion of cementless implants the intravasation of embolic material seems to be less, but it is likewise possible to have a thromboembolic complication during cementless THA. However, it is not justified as a consequence to use the thromboembolic risk as the main indication for implant choice, in particular as the overall risk of a serious fatal complication is low.

The efficacy of low-pressure lavage with different irrigating solutions to remove adherent bacteria from bone.

Recent studies have suggested that high-pressure irrigation may have adverse effects on bone. However, the use of low-pressure irrigation may not remove all adherent bacteria from bone. The type of irrigating solution may be an important factor in the removal of adherent bacteria with pulsatile lavage. In this study, we compared the effects of various irrigating solutions on the number and function of osteoblasts and osteoclasts and we examined the effectiveness of these solutions in removing adherent bacteria from bone. To examine the effect of irrigating solutions on the number and activity of osteoblasts, we isolated calvarial cells from newborn C57BI/6 mice and exposed the cells to equivalent concentrations of ethanol, povidoneiodine, liquid soap, antimicrobial wash (50 U/L of bacitracin), or chlorhexidine gluconate, for two, ten, or twenty minutes. The cells were then cultured in the presence of bone-nodule-enhancing medium (beta-glycerophosphate and ascorbic acid) for twenty-one days. The medium was changed every three or four days. Mineralized nodules were stained with alizarin red S, and osteoblasts were stained with a histochemical stain for alkaline phosphatase. Osteoclasts were identified with tartrate-resistant acid-phosphatase staining. In a second experiment, canine cortical tibiae were contaminated with Staphylococcus aureus for six hours and subjected to different irrigating solutions with or without low-pressure lavage. Bacterial colony-forming units were quantitated under each set of conditions. Each solution resulted in a time-dependent decrease in the number of calvarial osteoblasts and osteoclasts compared with that in the controls. The 1% soap solution resulted in greater preservation of both alkaline-phosphatase activity and bone-nodule formation than did the other solutions. Moreover, the soap solution preserved the number of osteoclasts to the greatest extent. The povidone-iodine and chlorhexidine-gluconate solutions resulted in the largest decline in bone-nodule formation, alkaline-phosphatase activity, and number of osteoclasts. Low-pressure pulsatile lavage with the soap solution removed the most bacteria from the contaminated tibia when compared with either the soap solution alone or low-pressure irrigation with saline solution. Our findings suggest that certain solutions may be more effective in removing bacteria from bone than mechanical irrigation with saline solution alone. Among the various solutions examined, the soap solution preserved the number and activity of osteoblasts the most. Low-pressure lavage with the soap solution resulted in the greatest removal of adherent bacteria from bone.

Cemented hip prosthesis implantation--decreasing the rate of fat embolism with pulsed pressure lavage

Intraoperative fat embolism associated with cemented total hip arthroplasty is a well recognized complication. In a new sheep model allowing for standardized bilateral, simultaneous cement pressurization we studied the effectiveness of both pulsatile and syringe lavage of equal volume with regard to their cleansing capabilities as measured by fat and bone marrow intravasation. The operative procedure involved bilateral placement of intravenous catheters into the external iliac veins via retroperitoneal approach. After femoral neck osteotomies both femoral cavities were prepared for retrograde cement application. After randomization one side was lavaged with 250 ml irrigation using a bladder syringe, the contralateral femur with the identical volume but using a pulsatile lavage. A specially designed apparatus was used to allow for bilateral simultaneous cement pressurization. Venous blood from both iliac catheters was then collected, anticoagulated and a quantitative and qualitative fat analysis was performed. Despite equal volume manual lavage produced significantly higher fat and bone marrow intravasation (P < 0.001) than pulsatile lavage thus suggesting that not only the volume but also the quality of bone lavage is an essential factor influencing the risk of fat embolism and adverse cardiorespiratory effects. Our findings further emphasize the important role of pulsatile lavage in preventing fat and bone marrow embolisation during cemented total hip arthroplasty.

High and low pressure pulsatile lavage of contaminated tibial fractures: an in vitro study of bacterial adherence and bone damage.

This study was designed to examine the effect of pulsatile irrigation on microscopic bone architecture and its time-dependent efficacy in removing adherent slime-producing bacteria from cortical bone. Using an in vitro model, ten-millimeter transverse cut sections from five human tibiae were contaminated with Staphylococcus aureus and subjected to either high pressure pulsatile lavage (HPPL; seventy pounds per square inch, normal saline) or low pressure pulsatile lavage (LPPL; fourteen pounds per square inch, normal saline) or served as controls. Alteration of bony architecture was quantified by using a previously described ordinal scale and histomorphometric analysis of each transverse cut section of tibia. To assess the time-dependent effectiveness of pulsatile lavage in removing adherent bacteria from bone, ten-millimeter transverse cut sections from ten canine tibiae were contaminated with S. aureus and subjected to high or low pressure pulsatile lavage immediately or after one, three, or six hours. Scanning electron microscopy and bacterial cultures were used to assess the removal of adherent bacteria. HPPL resulted in significantly greater macroscopic damage than was seen with LPPL or in controls (ANOVA, p < 0.001). Histomorphometry revealed that HPPL was associated with significantly larger and more numerous fissures or defects in the cortical bone when compared with low pressure irrigation (p < 0.001). However, high and low pressure lavage were associated with similar degrees of periosteal separation from the cortical bone surface (p = 0.87). Both high and low pressure lavage were effective in removing adherent bacteria from bone at three hours irrigation delay, but only high pressure lavage removed adherent bacteria from bone at six hours delay. In this in vitro study, compared with HPPL, LPPL led to less structural damage and was equally effective in removing bacteria within three hours debridement delay; however, the efficacy of LPPL at six hours debridement delay is questionable. This finding may have clinical significance in the development of infection following open tibial fractures.

Efficacy of irrigation for removal of particulate debris after cemented total knee arthroplasty

We studied the amount of particulate debris removed with pulsatile lavage irrigation before and after component implantation in 13 consecutive patients undergoing primary cemented total knee arthroplasty (TKA) done by a single surgeon. Before component implantation, the knees were copiously lavaged with 3 L of pressurized irrigant; all fluid was collected in 1 aliquot using standard wall suction canisters. After cementing the components in place, another 3 L of pressurized irrigant was used; this fluid was collected in 3 sequentially labeled 1-L aliquots. Collected fluids were centrifuged, and the residue was washed, recentrifuged, and dried. Residual particulate debris was quantitated by weight. An average of 537 mg/L (range, 16–1,406 mg/L) of debris were removed before implantation with 3 L of irrigation. An average of 217 mg/L (range, 31–999 mg/L), 52 mg/L (range, 0–189 mg/L), and 49 mg/L (range, 1–185 mg/L) of debris was removed after implantation with each of the additional liters. Using analysis of variance testing, there was a statistically significant difference between the amount of debris removed with 3 L and after 4 L ( P = .02) and 5 L ( P = .03) of irrigant. There was no statistical difference between irrigation with 5 L and 6 L of irrigation ( P = .92). The residua particulate debris was also analyzed to determine the relative amounts of bone-soluable organics and polymethyl methacrylate (PMMA). Before implantation, the residual debris, by weight, consisted of 79% bone and 21% soluable organics. We found on average that after implantation of components the specimens contained 53% bone and 47% PMMA and soluable organics by weight. We believe that despite careful implantation and meticulous cement technique, large amounts of debris, including bone and PMMA, remain after TKA, which require at least several liters of pulsatile lavage to removed. Removal of this particulate debris may decrease third-body polyethylene wear.

The use of Pulsed Lavage with Integral Suction in Total Hip Replacement

Both pulsatile lavage and distal femoral plugs are used routinely in preparation of the femoral canal prior to cementing. Using an in-vitro model, two types of pulsed lavage irrigation systems were tested to assess their relative abilities to clear the femoral canal of the polethylene vanes which commonly become detached from the Hardinge type of cement restrictor during insertion. The narrower tipped system, which did not incorporate an integral suction system, performed significantly better. Surgeons should be aware of this potential problem when preparing the femoral canal.