Debride and prejudice – why is pulsed lavage so important in wound care and orthopaedics?
One of the earliest references to the clinical use of pulsed lavage in wound cleansing, was in a 1978 clinical note in Physical Therapy, in which Nourse and Myrers outlined the use of a dental irrigating device to cleanse a pressure ulcer. [*1]
Pulsed Lavage is a form of mechanical hydrotherapy used to debride wounds and necrotic tissue, and to remove debris from a wound, particularly prior to hip and knee arthroplasty. Studies suggest that that debriding wounds with a Pulse Lavage can improve the growth of tissue by removing debris and necrotic tissue without damaging or disrupting the underlying normal tissues. [*3]
But what evidence is there to support these claims, and what makes a good Pulse Lavage?
Read on for our four key features and facts to consider when choosing a Pulse Lavage.
Pulsed Lavage in joint procedures, revisions and wound care
Wound cleansing is essential in wound management and is used to facilitate the healing process. In the 1950s, Liedberg et al showed that when bacterial concentrations of streptococci, pseudomonas, or staphylococci w ere greater than 100,000 organisms per gram in tissues, skin grafts on rabbits were destroyed. Nearly 20 years later in 1969, Robson and Heggers summarized military and civilian studies examining the critical level of bacterial burden necessary to produce wound sepsis and failure to heal. They concluded that wound healing is possible only when bacterial counts are maintained at a concentration of 100,000 organisms per gram or less. [*1]
A further study by Constantine and Bolton surmised that the presence of necrotic tissue or eschar, within a wound or at the wound’s margin, impedes wound contraction and closure.
Research concluded that necrotic tissue in a wound provides an environment that facilitates wound infection. Current medical practice includes wound cleansing and debridement to remove impediments to the healing process to facilitate the progression from the inflammatory phase to the proliferative phase of wound healing. [*1]
Of course, Pulsed Lavage isn’t the only option for wound debridement. However, research suggests that irrigation with pressures of less than 4 psi may be insufficient to remove surface pathogens and debris, but that irrigation pressures of greater than 15 psi may cause wound trauma, or even drive bacteria into the wounds. *1 Some of the most common wound cleansing methods include pour or squeeze bottles, bulb or piston syringes, piston irrigation, and whirlpool agitation. [*1]
Controlled pulsatile irrigation and suction
There is limited research comparing the effectiveness of whirlpool (one of the oldest types of hydrotherapy *4) versus pulsed lavage in wound cleansing. However, there are two studies that suggest pulsed lavage following whirlpool agitation is more effective at removing bacteria than pulsed lavage alone. A more recent study found that pulsed lavage was more effective than whirlpool in promoting wound healing. [*1]
Irrigation under pressure may be delivered concurrently with suction, removing the irrigating solution from the target area. In wound cleansing, pulsed lavage is used to remove infectious agents and debris from a wound’s surface. This method of wound cleansing is known by various names, including “lavage,” “jet lavage,” “mechanical lavage,” “pulsatile lavage,” “mechanical irrigation,” and “high-pressure irrigation.” [*1]
Haynes et al compared the effects of pulsed lavage and whirlpool on the rate of formation of granulation tissue in 13 subjects with a variety of chronic open wounds. Seven subjects received pulsed lavage, and 6 subjects received whirlpool. The rate of granulation tissue formation for patients receiving pulsed lavage (12.2% per week) was greater than the granulation rate of patients receiving whirlpool (4.8% per week). [*1]
Pressure up to 15 psi
Rodeheaver et al studied the effect of irrigation on the removal of S aureus and soil particles from experimentally contaminated wounds in 4 groups of rats. Each group was exposed to 1 of 4 impact pressures: 1, 5, 10, or 15 psi. Impact pressures of both 1 and 5 psi, although removing 48.6% and 50.3% of the contaminants, respectively, were ineffective at preventing infection. In both of these groups, the rats developed clinical wound infections.
The groups exposed to impact pressures of 10 and 15 psi experienced removal of 75.7% and 84.8% of wound contaminants, respectively. The infection rates of these groups were lower than incidence rates for the group exposed to irrigation at an impact pressure of 1 psi. [*1]
At the other end of the scale, there are concerns that using too much pressure in pulsed lavage wound cleansing could cause further damage.
There have been a number of studies which investigate potential risks around high-pressure pulse lavage. These include the development of bacteraemia following lavage of contamination of wounds, traumatisation of wounds and dissemination of particulate matter or bacteria through the wound to surrounding tissues. [*1]
Improvement of joint replacement fixation strength
As well as its use in wound debridement, pulse lavage is widely used in orthopaedics, particularly in hip and knee arthroplasty, to prepare the surgical site for the new joint. Pulsatile irrigation is said to improve radiographic survival in cemented total knee replacement. In addition, a potential improvement of fixation strength has been assumed, based on increased cement penetration. Aseptic loosening of the cemented tibial bone component can be problematic and is one of the main reasons for failure. The bone-cement interface is especially critical in terms of implant survival.
One study set out to evaluate the influence of pulsed lavage on fixation strength of the tibial component and bone cement penetration. The study was carried out in six pairs of cadaveric specimens. Following surgical preparation, the tibial surface was irrigated using pulsatile lavage on one side of a pair, while on the other side syringe lavage was applied. All tibial components were implanted using the same cementing technique. Fixation strength of the tibial trays was determined by a pull-out test with a material testing machine. Median pull-out forces and cement penetration were significantly improved in the pulsed lavage group as compared to the syringe lavage group. The study concluded that pulsatile lavage should be considered as a mandatory preparation step when cementing tibial components in total knee arthroplasty. [*2]
The above studies conclude that Pulsed Lavage is beneficial in both wound debridement, as it can aid healing, and joint replacement, as it can improve radiographic survival of a new joint.
Our Pulse Lavage is a cost effective, single-use solution. The Single Use Professional Pulse Lavage (S353) has a built-in battery pack and is supplied with 2 tips (Long Coaxial Canal (Femoral) Tip, and 30mm Cone Tip). It is suitable for use in total joint procedures, orthopaedic revisions and trauma and wound care.
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