Die Bedeutung der Jet-Lavage für das In-vitro- und In-vivo-Zementierergebnis[1]

Zusammenfassung.

Fragestellung: Ziel dieser Studie war es, die Effektivität der pulsierenden Druckspülung (Jet-Lavage) gegenüber der manuellen Spritzenspülung im Hinblick auf das Zementierergebnis am Femur standardisiert in vitro und in vivo zu untersuchen. Methode: Zur Bearbeitung der Fragestellung wurden drei Teilversuche durchgeführt. Versuch A: An 36 linken humanen Leichenfemora wurden mit standardisierter Präparationstechnik und retrograder Druckzementiertechnik („pressurising”) Femurschaftprothesen implantiert. Zwei verschiedene Zementiergruppen wurden randomisiert. Je nach Gruppe erfolgte die Knochenlagerspülung entweder mit Jet-Lavage oder Blasenspritze, jeweils mit gleichem Spülvolumen. Versuch B: Um standardisierte Druckverhältnisse und seitengleiche Knochenqualität zu gewährleisten, wurde eine Zusatzstudie ohne Prothesenimplantation an 11 humanen Femurpaaren durchgeführt. Dabei unterschieden sich die präparierten Femurpaare lediglich hinsichtlich Spülart (1000 ml Jet-Lavage versus 1000 ml Blasenspritze). Alle Präparate wurden nach Knochenspülung in speziell angefertigte Kunststoffzylinder eingegipst. Nach retrograder Zementapplikation erfolgte die Druckbeaufschlagung des Zementes mit einer konstanten Kraft von 3000 N. Versuch C: Um die Zementpenetration in Abhängigkeit von der Knochenspülung in vivo beurteilen zu können, erfolgte im Rahmen eines neuen Schafmodells die standardisierte bilaterale und simultane Zementeinbringung und -kompression. Nach der Schenkelhalsosteotomie wurden beide Femora für die retrograde Zementeinbringung präpariert. Nach Randomisierung wurde eine Seite entweder manuell mit 250 ml Spülung oder mit dem identischen Volumen mittels Jet-Lavage gespült. Durch eine speziell für diesen Versuch angefertigte Zementkompressionsmaschine wurde anschließend im geschlossenen System der retrograd eingebrachte Zement simultan mit gleichem Druck komprimiert. Präparateaufarbeitung: Von allen Präparaten (Versuche A - C) wurden in regelmäßigen, standardisierten Abständen horizontale Sägeschnitte angefertigt. Von den erhaltenen Knochenscheiben wurden Mikroradiogramme erstellt und diese mittels Bildanalyse hinsichtlich der Zementpenetrationstiefe morphometrisch ausgewertet. Ergebnisse: Versuch A: Die Verwendung der Jet-Lavage erbrachte im Vergleich zu den manuell mittels Blasenspritze gespülten Femora signifikant bessere Zementpenetrationstiefen (p = 0,027). Bei dichter Spongiosa war der Unterschied zwischen Jet-Lavage und Blasenspritzenspülung stärker ausgeprägt. Versuch B: Im Links-rechts-Vergleich führte die Verwendung der Jet-Lavage im Vergleich zur manuellen Spülung bei gleichem Druck und Spülvolumen zu einer signifikante Verbesserung der Penetrationstiefe (p < 0,001).Versuch C: Auch im direkten Links-rechts-Vergleich in vivo bestätigte sich die signifikante Überlegenheit der Jet-Lavage (p = 0,002). Schlussfolgerungen: Die Verwendung der Jet-Lavage hat in vitro und in vivo wesentlichen Einfluss auf die verbesserte Penetrationstiefe von Knochenzement in das angrenzende Knochenlager und sollte in der zementierten Hüftendoprothetik sowohl aus zementiertechnischer Sicht als auch im Hinblick auf die Senkung des Fettembolierisikos als unverzichtbar angesehen werden.

Aim: 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. Methods: 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 additonal 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. Analysis: 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. Results: 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). Conclusions: 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.

Schlüsselwörter:

Hüftendoprothetik - Knochenzement - Zementiertechnik - Lavage - Zementmantel - Fettembolie

Key words:

total hip arthroplasty - bone cement - cementing techniques - pulsatile lavage - cement mantle - fat embolism

01 Diese Arbeit wurde mit dem Themistocles-Gluck-Preis der DGOT 2000 prämiiert. Teile der Arbeit wurden bereits veröffentlicht im Orthopäden (Literaturstelle 19).

Literatur

01 Diese Arbeit wurde mit dem Themistocles-Gluck-Preis der DGOT 2000 prämiiert. Teile der Arbeit wurden bereits veröffentlicht im Orthopäden (Literaturstelle 19).

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