Pulsatile Lavage During Cementation of Total Knee Arthroplasty - Is Fixation Impaired? A Cadaver Study

Abstract

Background/Aim: Increasing economic pressure in modern healthcare necessitates an increase in efficiency in total knee arthroplasty (TKA) while maintaining highquality outcomes. Removal of debris using pulsatile lavage (PL) during cement polymerization may considerably reduce the operative duration. However, water can penetrate the interface, resulting in impaired implant fixation. The aim of the present study was to investigate the impact of early-onset PL during bone cement polymerization on implant fixation and operative duration. Materials and Methods: Cemented implantation of tibial trays was performed in 20 fresh-frozen human tibiae from 10 donors in a matched-pair study design in two groups: 1) PL during cement polymerization; and 2) PL after completion of the polymerization process. The cement penetration depth was analysed by computed tomography (CT), and the pull-out force was measured to evaluate primary implant fixation. The duration of the procedure was recorded for both groups. Results: Comparable pull-out forces were observed in the experimental (2,213 N) and control groups (2,350 N; p=0.68). The mean depth of cement penetration was similar in both groups. PL during cement polymerization could decrease the operative duration by 10 min. Conclusion: The application of PL during cement polymerization could significantly reduce operative duration and had no adverse effect on the mechanical fixation of the tibial component.Osteoarthritis of the knee is one of the most common joint disorders in adults, and total knee arthroplasty (TKA) is the only causal therapy for end-stage osteoarthritis. Despite already high numbers of primary TKA procedures, a further increase is expected due to demographic development in modern industrialized countries (1). TKA is thus a highly effective routine procedure with high patient satisfaction rates and a good implant survival rate of more than 90% after 10-15 years (2).However, despite good to excellent overall survival rates, early aseptic loosening remains one of the leading causes for revision surgery (3). In this context, there has been an increased interest in cementless TKA in recent years, particularly for younger and more active patients (4, 5). However, cemented fixation is still considered the gold standard in TKA (4). Thus, optimization of the cementation technique to increase cement penetration depth is a decisive factor for primary stability (6). In this context, a cement penetration depth of 3-5 mm is known to reduce micromotion at the bone-cement interface, potentially improving implant survival (7-9).The necessity of a thorough cementation and implantation technique stands opposed to the continuously increasing cost pressure and demand for surgical procedures of shorter durations in modern healthcare systems. Regarding TKA, pulsatile lavage (PL) should be used not only for the preparation of the bone stock prior to implantation but also for the removal of bone and cement debris following the implantation process to avoid increased wear rates (10-12). The ...