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Intraosseous suction and carbon dioxide gas lavage may offer better fixation
Too much pressure during intraosseous suction for hip resurfacing could lead to overcementing.
Some surgeons are turning to a novel gas lavage system and intraosseous suction to increase cement fixation for total knee arthroplasty and hip resurfacing procedures.
Surgeons using the Carbo-Jet Lavage System [Kinamed], a carbon dioxide (CO2) compressed gas jet, are finding better cement penetration than water jet lavage provides for total knee arthroplasty (TKA).
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Images: Kinamed Inc. |
“I can really say that it’s been nothing but positive for knees,” Richard E. Jones, MD, told Orthopedics Today. “We’ve had no untoward effects and [we’ve had] significant short-term benefits in terms of cement penetration on the X-rays and of fixation of the component.”
The system delivers high-pressure CO2 through a filter and removes fat and debris from the bone. “Even after you use the water jet, there’s still a pretty radical difference in what you can do further with the Carbo-Jet, because the Carbo-Jet allows you to clean all of the cancellous interstices. … Therefore, you get a much better bond with the cement,” Jones said.
He has used the system for nearly 10 years with favorable results.
“While we have not been using it long enough to say that we have 20-year results that [indicate] it is better, very clearly our initial looks, particularly in total knees, show that we get more depth of penetration of the cement and a better stress transition gradient [with the Carbo-Jet],” Jones said.
The gradient translates into potentially longer fixation. “That same penetration and lack of any bone loss has maintained itself in our follow-up films as we go out to 10 years,” Jones said. “It’s still looking good and we have no loosening.”
He said the deeper cement penetration does not increase the difficulty of a revision. “But the fact that it gives you a better chance not to have a revision, because you’re going to have less loosening of the implant is, again, one of the big pluses from the standpoint of knees,” Jones said.
Intraosseous suction
In his research, British investigator Keith S. Eyres, FRCS, also found that the approach shows better X-rays and significantly less radiolucency at 5-year follow-up using intraosseous suction for TKAs performed without tourniquets.
“This would constitute [that] an improvement in cementing techniques by optimizing the operative field in tourniquet-free surgery and possibly improve the longevity of the implant,” Eyres told Orthopedics Today. The presence of the cannula also provides a vent to decompress the long bone and reduce embolic events. “The effects are enhanced further when navigation systems are used, since the femur is a closed box and the suction is more effective. This could represent a major advance to reduce any doubts about the risks of bilateral knee replacement surgery.”
During procedures, Eyres places a canula into the distal femur to reduce the risk of fat emboli during penetration with alignment rods and then applies suction to reduce blood contamination of the operative field. He then inserts the cannula into the tibia for irrigation and suction. “The technique decreases blood flow, maintains a dry surgical area for cementing and significantly improves the cement mantle to the trabeculae. It enhances tourniquet-free surgery and improves postoperative X-ray appearances which may translate into increased implant survival,” he said. “These effects are also seen when a tourniquet is used.”
Hip resurfacing
Harlan C. Amstutz, MD, is also using intraosseous suction for hip resurfacing and more recently the Carbo-Jet. “The two most important facets of optimizing acrylic cement for fixation are cleaning and drying the bone,” Amstutz told Orthopedics Today. This is especially important in femoral resurfacing where the surface area is small compared the area for a stem-type device. The cystic material is removed from the head with a burr and lavage and drying is facilitated by intraosseous suction both to help dry it and to keep it dry. “In the case of the femoral head for resurfacing, you put a suction tip into the femur distal to the femoral head in the lesser trochanter and combine that with a suction that is placed down the central hole in the femoral head.”
The Carbo-Jet adds another dimension for drying the head. “I don’t know how much the Carbo-Jet adds because fixation has been so good with the prior improvements made by cleaning and suction drying that we’re not experiencing any retrievals, but I do feel that it is a helpful adjunct.” He added, “The Carbo-Jet also aids in identifying remaining soft tissue so that it can be removed.”
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Total hip arthroplasty
Although U.S. surgeons have shifted to using pressfit fixation, some researchers said that both techniques could be beneficial for total hip procedures that require cement.
Jones said that an attachment on the Carbo-Jet allows surgeons to fully clean the intramedullary canal, which could prevent fat emboli.
In an ongoing study, researchers are using transesophageal cardiogram signals to determine if the Carbo-Jet can decrease debris in the blood stream and subsequent pulmonary emboli, Jones said.
While Amstutz said he has not used intraosseous suction for total hips, he acknowledged that the technique could be applicable to these cases.
“I think the concept is a good one, [but] it just maybe needs to be refined in terms of how much suction [is needed] and where do you put the cannulas optimally,” he said.
Still, John J. Callaghan, MD, said that pressurization techniques and tourniquet use would make intraosseous suction unnecessary for most total hip and knee cases.
“We think that just using epinephrine-soaked sponges when there’s any blood and pressurizing cement into the canal, whether it be the femur of the hip or on knees, provides great long-term results,” he told Orthopedics Today.
For more information:
- Harlan C. Amstutz, MD, Joint Replacement Institute, 2400 S. Flower Street, Los Angeles, CA 90007; 213-744-1175; jri_oh@compuserve.com. He is a consultant for Wright Medical.
- John J. Callaghan, MD, University of Iowa Health Care, 200 Hawkins Drive, Iowa City, Iowa, and the Veterans Administration Hospital, Iowa City, Iowa; 52242; 319-353-6754; john-callaghan@uiowa.edu. He has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.
- Keith S. Eyres, FRCS, Princess Elizabeth Orthopaedic Centre, Exeter, Devon, England; eyres@talktalk.net. He indicated that he has no direct financial interest in the products discussed in this article nor is he is a paid consultant for any companies mentioned.
- Richard E. Jones, MD, Orthopedic Specialists, 5920 Forest Park Road, Suite 600, Dallas, TX 75235; 214-350-2225; dickeyjonesortho@aol.com. He is a consultant for Kinamed.