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.

A rare and uncommon complication after use of hydrogen peroxide (H2O2): A review of use of H2O2 in orthopaedics

Hydrogen peroxide (H2O2) is a commonly used chemical agent in orthopaedic practice for antisepsis, haemostasis and preparation of bone bed for cementation. However, the associated risks of H2O2 usage are not widely known. We report a case of suspected air embolism after use of H2O2 during drainage of a septic arthritis of the shoulder. Upon our literature review, we were able to demonstrate H2O2 to be beneficial in antisepsis and care of chronic wounds. However, it has not been proven to be superior to other antiseptics commonly used in orthopaedic surgery. Regarding its use in cementation, there is evidence to show it is more effective than saline however, the use of pulsatile lavage appears to be the most important factor affecting the quality of cementation. H2O2 has not been shown to be helpful with haemostasis. Prior to the use of H2O2, one should be cautious and understand its associated risks and precautions.

Osteochondral Allograft Transplantation: Identifying the Biomechanical Impact of Using Shorter Grafts and Pulsatile Lavage on Graft Stability

Objectives: This study seeks to identify the ability of shorter Osteochondral Allografts (OCAs) to resist displacement/failure. Additionally, this study seeks to evaluate the effect of pulsatile lavage on the biomechanical stability of the OCA graft. Methods: Fifteen millimeter diameter, human cadaveric, osteochondral allografts of 4 mm, 7 mm, and 10 mm in depth were harvested for comparison of resistance to compressive and tensile loads. For each group 7 specimens were subjected to tensile loads and 3 specimens subjected to compressive loads until failure (pull-out or subsidence). An additional study group of 10 pulsatile lavaged (PL) osteochondral allografts of 15 mm in diameter and 7 mm in depth were introduced for comparison to the original 7 mm depth OCA group. Results: The average tensile forces for failure for the 4 mm, 7 mm, and 10 mm plugs were 23.74 N, 199.57 N and 197.69 N respectively (p=1.5x10-5). After post-hoc analysis of the tensile groups, significant differences in the mean tensile force to failure were appreciated between the 4 mm and 7 mm groups (p=4.12 x10-5) and the 4 mm and 10 mm groups (p=1.78x10-5), but not between the 7 mm and 10 mm groups (p=.9601). There were no significant differences between the average tensile forces resulting in failure for the 7 mm and 7mm-PL groups (199.57 N and 205.2 N, p=.90) or compressive forces to failure respectively (733.6 N and 656 N, p=.7062). Conclusion: For OCAs of 15 mm in diameter, a commonly used size in practice, we recommend that plugs of 7 mm in depth be utilized. Pulsatile lavage of allografts prior to insertion does not appear to take away from the structural integrity and stability of the plug, however an adequately powered study should confirm this. With many described theoretical benefits of decreased immunogenicity and better long term graft incorporation after lavage, we recommend that this practice continue. [Table: see text]

Osteochondral Allograft Transplantation: Identifying the Biomechanical Impact of Using Shorter Grafts and Pulsatile Lavage on Graft Stability

This study seeks to identify the ability of shorter osteochondral allografts (OCAs) to resist displacement/failure. Additionally, this study seeks to evaluate the effect of pulsatile lavage (PL) on the biomechanical stability of the OCA. Fifteen-millimeter diameter, human cadaveric, OCAs of 4, 7, and 10 mm in depth were harvested for comparison of resistance to compressive and tensile loads. For each group, seven specimens were subjected to tensile loads and three specimens subjected to compressive loads until failure (pullout or subsidence). An additional study group of 10 pulsatile-lavaged OCAs of 15 mm in diameter and 7 mm in depth were introduced for comparison to the original 7 mm depth OCA group. The average tensile forces for failure for the 4, 7, and 10 mm plugs were 23.74, 199.57, and 197.69 N, respectively (p = 1.5 × 10−5). After post hoc analysis of the tensile groups, significant differences in the mean tensile force to failure were appreciated between the 4 and 7 mm groups (p = 4.12 × 10−5) and the 4 and 10 mm groups (p = 1.78 × 10−5) but not between the 7 and 10 mm groups (p = 0.9601). There were no significant differences between the average tensile forces resulting in failure for the 7 mm and 7 mm PL groups (199.57 and 205.2 N, p = 0.90) or compressive forces to failure, respectively (733.6 and 656 N, p = 0.7062). For OCAs of 15 mm in diameter, a commonly used size in practice, plugs of 7 mm in depth showed comparable resistance to pull out and subsidence as 10 mm plugs and significantly better resistance to pull out than 4 mm grafts. PL of allografts prior to insertion did not take away from the structural integrity and stability of the plug.

Pulsatile lavage for wound debridement in compound fractures of leg: a randomized control trial

<p class="abstract"><strong>Background:</strong> Management of compound fractures is a real challenge to the orthopaedic surgeon. Thorough wound irrigation and debridement is necessary to get a good outcome. Power-pulsed lavage (PPL) is a method of wound irrigation that has been popularised as an adjuvant in wound debridement.</p><p class="abstract"><strong>Methods:</strong> 39 patients of 28 to 40 years with Gustilo Anderson Type II and Type III fractures were divided in to two groups randomly and given pulsatile lavage or continuous flow lavage. Both the groups were followed up from January 2014 to January 2016, microbiology of the swab collected, pre and post lavage, and various other factors influencing the outcome were studied.<strong></strong></p><p class="abstract"><strong>Results:</strong> Most of the successful outcome was in the age group of 25-29 years (46.7%) and in the male gender 66.7%. The success outcome rate was 73.3% in those with Type II Gustilo Anderson fracture compared to Type III (26.7%). All persons with successful outcome had Tscherne grade II fracture. Also a clean or clean contaminated wound (CDC classification) had more chance for successful outcome (86.7%) than contaminated or dirty wounds.</p><p><strong>Conclusions:</strong> Heavy growth in pre-lavage blood agar culture was the single most important factor that determines the persistence of infection in compound fracture of both bones of leg. Type of lavage did not affect the union of fracture because presence of radiological signs of union was comparable in pulsatile group (66.7%) and continuous flow group (61.9%). </p>

In Vitro Characterization of Lavage Splash and Effectiveness of Lavage Shield

BACKGROUND: Utilization of fluid to remove debris from surgical wounds has been a standard of medical care for centuries. Electrically powered pulse lavage systems are now regularly used to flush wounds in the operating room. This study aims to characterize splash patterns and contamination generated by different irrigation techniques commonly used in the treatment of surgical wounds.METHODS: 4 different irrigation scenarios: gravity flow (GF), asepto bulb syringe (ABS), high pressure pulsatile lavage without splash shield (HPPL), and high pressure pulsatile lavage with splash shielding (HPPL-S) were conducted on a Sawbone® knee model anchored to a standard operating table in a fully operational operating room of a community hospital. Normal saline supplemented with Fluorescein dye was utilized as the fluid. The OR was divided into 4 quadrants and surveyed with a UV light source to characterize the presence of fluorescent fluid/droplets and radius of droplet displacement.RESULTS: The HPPL trials contaminated the entire room with droplets that were too numerous to count. The HPPL-S trials reduced the number of droplets in quadrants outside of the “head right” quadrants, to a range of 0-12 droplets. In addition, the HPPL-S trial reduced the droplet distance to levels comparable to or below the GF and ABS droplet distance.DISCUSSION: This is the first study to characterize splash patterns seen with different irrigation systems. The addition of an inexpensive splashguard during high-pressure irrigation drastically reduced splash displacement. Decreased splash displacement theoretically reduces OR contamination and the resultant risk of nosocomial contamination.

Pulsatile Lavage for the Enhancement of Pressure Ulcer Healing: A Randomized Controlled Trial

Background Pressure ulcer development is a common, serious complication after spinal cord injury (SCI). Although many biophysical agents are available for treatment, few randomized controlled trials of their efficacy have been done. Objective The study objective was to examine the efficacy of low-pressure pulsatile lavage treatment for stage III and IV pressure ulcers in people with SCI. Design This study was a randomized controlled trial. Participants and assessors were unaware of intervention assignments. Setting This study was conducted in an SCI tertiary care center inpatient unit. Participants Participants were 28 people with SCI and stage III and IV pelvic pressure ulcers; 14 participants each were randomly assigned to treatment and control (sham treatment) groups. Intervention Daily low-pressure pulsatile lavage treatment with 1 L of normal saline at 11 psi of pressure was applied to the treatment group along with standard dressing changes. The control group received only sham treatment and standard dressing changes. Measurements Linear and volume measurements of pressure ulcer dimensions were obtained weekly for 3 weeks. Results Statistical analysis with the t test revealed no statistically significant difference in demographics between groups. Random-coefficient models for analysis of linear and volume measurements revealed improvements over time for both groups. Time trend analysis revealed greater measurement decreases for the treatment group. Differences in rates of change (with 95% confidence intervals) for treatment and control groups, respectively, were: depth, −0.24 (0.09 to −0.58) cm/wk; width, −0.16 (0.06 to −0.39) cm/wk; length, −0.47 (0.18 to −1.12) cm/wk; and volume, −0.33 (0.13 to −0.80) cm3/wk. Limitations Study limitations were small sample size and inclusion of only one site. Additionally, participants were not queried about their group assignments. Conclusions Pulsatile lavage enhanced stage III and IV pelvic pressure ulcer healing rates in people with SCI relative to standard pressure ulcer treatment alone.