Introduction: Hot swollen knee joints are a common presentation in clinical practice. It has wide differential diagnoses, the most serious being septic arthritis. Delayed or inadequate treatment leads to joint damage. Arthroscopic lavage should be planned appropriately after proper clinical assessment and investigation. Other differential diagnoses like crystal arthritis, reactive arthritis, monoarticular inflammatory arthritis should be considered. Patients and Methods: This retrospective audit involved 44 patients who had arthroscopic knee lavage for suspected septic arthritis from January 2005 to May 2007. Analysis included the aspects of adequate backup supportive evidence for the procedure, the time from diagnosis to operation and postoperative antibiotic regime. Results: There were 29 males and 15 females with age group ranging from 11 to 91 yrs. Fever was present in 15 patients(34%), preoperative joint aspiration done in 22(50%), peri-operatively pus found in 11(25%). 13 patients(29.5%) had procedure done within 6hrs, causal organism identified in 25%. Follow-up ranged upto 12 months without persistence or reactivation. Discussion: Arthroscopic lavage is a useful adjunct in treatment of septic arthritis of knees but proper patient selection with systematic approach considering other possible differential diagnoses is important for avoiding unnecessary operations

Purpose: To evaluate and compare the effect of arthroscopic depridement and lavage versus arthroscopic lavage only as a treatment in osteoarthritis of the knee. Type of Study: A prospective study. Material and Methods: 500 patients ( mean age 58 years ) were available for 6 years follow-up after arthroscopy of the knee as a treatment of osteoarthritis refractory to conservative treatment. 250 patients were treated with debridement and lavage and 250 patients were treated with lavage only. Osteoarthritis of the knee is a common cause of knee pain. The pain from osteoarthritis is due to synovitis, capsular and ligamentous inflammation, and subchondral bone pain because cartilage has no nerves. Degenerative arthritis is usually the end result of mechanical stress inflicted on the articular cartilage, either through a suddenly applied single load or through the cumulative effect of multiple or repetitive loads leads to breakdown of the articular cartilage. The treatment of knee pain due to osteoarthritis of the knee includes conservative treatment such as rest, weight loss, physical therapy, nonsteroidal anti-inflammatory drugs, Cox-II inhibitors, nutritional supplements, steroid injections, Viscosupplementation, and surgical treatment such as arthroscopy, osteotomy or arthroplasty. With failure of conservative treatment, arthroscopic debridement and lavage is the treatment of choice for such patients. Results: Arthroscopic debridement and lavage performed in earlier stages of osteoarthritis of the knee resulted in significant reduction of pain for long period of time. In advanced stages of osteoarthritis, patients experienced less pain relief for shorter period of time. Debridement and lavage was superior to lavage only at 6 years in reduction of pain. In my group 93.8% (91.2% of the lavage group and 96.4% of the debridement group) were satisfied at 6 months and felt better than before their surgery, at 3 years 45.6% (35.6% of the lavage group and 55.6% of the debridement group) felt better, and at 6 years 30.2% (22.8% of the lavage group and 37.6% of the debridement group) felt better after the arthroscopic procedure. Conclusions: Arthroscopic debridement and lavage of painful osteoarthritic knees has a better outcome than lavage only for the same treatment, however patients must be made aware that the procedure is not curative and that it is quite possible that they will need further surgery in the future. Arthroscopic surgery (debridement and lavage or even lavage only) is reasonably successful temporizing and palliative procedure. However, the patient must be informed about the prospects of success, the benefits, the alternative and the risks of that procedure

Aim. To evaluate the efficiency of pulse lavage combined with electrical fields to remove biofilm from a metallic surface. Method. Using a 12-well culture plate designed for the application of electrical fields, strains of S. epidermidis were incubated at each well for 24 hours at 37ºC. After incubation, supernatant culture medium was removed, and each well was filled with 3ml of normal saline. Six different models were compared: a) control, b) low-pressure pulse lavage, c) high-pressure pulse lavage, d) pulsed electrical fields, e) low-pressure pulse lavage in combination with pulsed electrical fields, and f) high-pressure pulse lavage in combination with pulsed electrical fields. In all cases, exposure time was set to 25 seconds. In the electrical field models, 50 pulses were applied. After exposure, each bottom electrode was scraped carefully to release adhered bacteria. Subsequently, different dilutions of biofilm removed were spread onto Müller Hinton agar plates and incubated for 24h at 37 ºC, and colony-forming units (CFU) per milliliters were counted. Bacterial counts were then compared to the control model. Results. High-pressure pulse lavage combined with pulsed electrical fields showed the greatest biofilm removal with reductions of up to 11.9 logarithms when compared to the control group. The lowest reduction was achieved by low-pressure pulsed lavage (4.7 logs). All reductions showed statistically significant differences. Conclusion. The results of our comparative study between different models demonstrates high reduction rates for biofilm removal. Further in vivo studies are needed to evaluate the capacity of the combination of high-pressure pulse lavage with pulsed electrical fields in removing bacterial biofilm in real conditions

Aims. In patients with a “dry” aspiration during the investigation of prosthetic joint infection (PJI), saline lavage is commonly used to obtain a sample for analysis. The aim of this study was to investigate prospectively the impact of saline lavage on synovial fluid analysis in revision arthroplasty. Methods. Patients undergoing revision hip (THA) or knee arthroplasty (TKA) for any septic or aseptic indication were enrolled. Intraoperatively, prior to arthrotomy, the maximum amount of fluid possible was aspirated to simulate a dry tap (pre-lavage) followed by the injection with 20 ml of normal saline and re-aspiration (post-lavage). Pre- and post-lavage synovial white blood cell (WBC) count, percent polymorphonuclear cells (%PMN), and cultures were compared. Results. A total of 78 patients had data available for analysis; 17 underwent revision THA and 61 underwent revision TKA. A total of 16 patients met modified Musculoskeletal Infection Society (MSIS) criteria for PJI. Pre- and post-lavage %PMNs were similar in septic patients (87% vs 85%) and aseptic patients (35% vs 39%). Pre- and post-lavage synovial fluid WBC count were far more disparate in septic (53,553 vs 8,275 WBCs) and aseptic (1,103 vs 268 WBCs) cohorts. At a cutoff of 80% PMN, the post-lavage aspirate had a sensitivity of 75% and specificity of 95%. At a cutoff of 3,000 WBCs, the post-lavage aspirate had a sensitivity of 63% and specificity of 98%. As the post-lavage synovial WBC count increased, the difference between pre- and post-lavage %PMN decreased (mean difference of 5% PMN in WBC < 3,000 vs mean difference 2% PMN in WBC > 3,000, p = 0.013). Of ten positive pre-lavage fluid cultures, only six remained positive post-lavage. Conclusion. While saline lavage aspiration significantly lowered the synovial WBC count, the %PMN remained similar, particularly at WBC counts of > 3,000. These findings suggest that in patients with a dry-tap, the %PMN of a saline lavage aspiration has reasonable sensitivity (75%) for the detection of PJI. Cite this article: Bone Joint J 2020;102-B(6 Supple A):138–144

Background. In the setting of a “dry” aspiration, saline lavage is commonly used to obtain a sample for analysis. The purpose of this study is to prospectively determine the impact of saline lavage on synovial fluid markers in revision arthroplasty. Methods. 79 patients undergoing revision hip (19) and knee (60) arthroplasty were enrolled. Intraoperatively, prior to arthrotomy, the maximum amount of fluid possible was aspirated to simulate a dry-tap (“pre-lavage”) followed by subsequent injection with 20 mL of normal saline and re-aspiration (“post-lavage”). Pre and post-lavage synovial white blood cell (WBC) count, percent polymorphonuclear cells (%PMN), and cultures were compared. Statistical analyses utilized the Wilcoxon signed-rank test. Results. Nine patients met modified MSIS criteria for prosthetic joint infection (PJI). Pre and post-lavage %PMN were similar in septic patients (90.1% vs. 88.2%, p=0.40 for septic). Pre and post-lavage WBC counts were different in both cohorts (69,432 vs. 6,547 WBCs, p=0.008 for septic; 1,850 vs. 449 WBCs for aseptic, p<0.001). Using a pre-lavage cutoff of >80% PMN, the post-lavage aspirate correctly identified 84.6% of true positives (sensitivity) and 98.5% of true negatives (specificity). Using a pre-lavage cutoff of >3000 WBCs, the post-lavage aspirate correctly identified only 38.1% of true positives (sensitivity). As the synovial fluid WBC count increased, the correlation between pre and post-lavage %PMN was stronger (mean difference of 7.0% PMN in WBC <3000 vs. mean difference −2.9% PMN in WBC >3000, p=0.002). Of seven positive pre-lavage fluid cultures, 4 remained positive post-lavage. Conclusion. While saline lavage aspiration significantly lowers the synovial WBC count, the %PMN is well maintained, particularly at WBC counts >3000. Our findings suggest that in the setting of a dry tap where saline lavage is required to obtain a sample, the %PMN has reasonable sensitivity and specificity for the detection of PJI. For figures, tables, or references, please contact authors directly

Despite proven advantages, pulsatile lavage seems to be used infrequently during preparation in cemented total knee arthroplasty. This remains irritating, as the technique has been suggested to improve radiological survival in cemented TKA, where aseptic loosening of the tibial component represents the main reason for revision. Furthermore, there may be a potential improvement of fixation strength for the tibial tray achieved by increased cement penetration. In this study, the influence of pulsed lavage on mechanical stability of the tibial component and bone cement penetration was analyzed in a cadaveric setting. Six pairs of cadaveric, proximal tibia specimen underwent computed tomography (CT) for assessment of bone mineral density (BMD) and exclusion of osseous lesions. Following surgical preparation, in one side of a pair, the tibial surface was irrigated using 1800ml normal saline and pulsatile lavage, while in the other side syringe lavage using the identical amount of fluid was applied. After careful drying, bone cement was hand-pressurized on the bone surface, tibial components were inserted and impacted in an identical way. After curing of cement, specimen underwent a postimplantation CT analysis). Cement distrubution was then assessed using a three-dimenionsional visualization software. Trabecular bone, cement and implant were segmented based on an automatic thresholding algorithm, which had been validated in a previous study. This allowed to determine median cement penetration for the entire cemented area. Furthermore, fixation strength of the tibial trays was determined by a vertical pull-out test using a servohydraulic material testing machine. Testing was performed under displacement control at a rate of 0,5mm/sec until implant failure. Data was described by median and range. Results were compared by a Wilcoxon matched pairs signed rank test with a type 1 error probability of 5 %. Median pull-out forces in the pulsed lavage group were 1275N (range 864–1391) and 568N (range 243–683) in the syringe lavage group (p=0.031). Cement penetration was likewise increased (p=0.031) in the pulsed lavage group (1.32mm; range 0.86–1.94), when compared to the syringe irrigated group (0.79mm; range 0.51–1.66). Failure occurred in the pulsatile lavage group at the implant-cement interface and in the syringe lavage group at the bone-cement interface, which indicates the weakness of the latter. Altogether, improved mechanical stability of the tibial implant and likewise increased bone cement interdigitation could be demonstrated in the current study, when pulsed lavage is implemented. Enhanced fixation strength was suggested being a key to improved survival of the implant. If this is the case, pulsatile lavage should be considered being a mandatory preparation step when cementing tibial components in TKA

Introduction: One of the most common complications following total joint surgery is aseptic loosening. Improving the bone-cement interlock may increase implant longevity. An ideally prepared bony surface is dry; clean; free from marrow, fat and debris; free from active bleeding; and free from micro-organisms. Lavage removes debris, blood and fat from the interstices of the bone surface so as to allow optimal penetration of the cement. The hypothesis that we investigated in this study was that lavage with a detergent solution obtains a greater depth of cement penetration into bone compared with lavage using 0.9% saline, hydrogen peroxide or an alcohol solution. Methods: The cancellous bone of ovine femoral condyles were cut into 10×10×13mm blocks. Lavage solutions were delivered via a pulsatile system and directed towards one side of the bone block. All blocks were swabbed dry. A high viscosity cement was manually mixed and applied to the sandblasted surface of titanium alloy plate (10×10mm, weight 0.9g ±0.01g). The titanium plate and cement were placed on the irrigated bone block, and a known weight applied to achieve pressurisation. Time, temperature and method were controlled. The prosthesis-cement-bone composite was sectioned perpendicularly, and image analysis used to quantify penetration depths. 10 readings were recorded per block with 6 blocks per lavage group. Results: Cancellous bone porosity averaged 75.2% (±4.0) . The mean penetration depth in the saline group averaged 3.39mm (± 0.77); 3.04mm (± 0.59) using a 2% alcohol solution; 3.33mm (±0.79) using a 3% hydrogen peroxide solution; and 5.41mm (± 1.30) when using the detergent lavage. There was no significant difference in cement penetration depth between hydrogen peroxide and saline irrigation (p> 0.05), nor with hydrogen peroxide and alcohol irrigation (p> 0.05). Irrigation with saline however, afforded statistically superior cement penetration than that of alcohol lavage (p < 0.012). Irrigation with detergent solution demonstrated significantly greater depth of penetration than all three other lavage groups (saline p< 0.05; alcohol p< 0.05; hydrogen peroxide p< 0.05). Discussion: Detergents can physically remove particulate matter and emulsify and remove fats, thereby acting to maximise porosity of the cancellous bone network and optimise space for occupation by intruding cement. This study has proven the ability of a detergent solution to provide a clean, debris free cancellous network, which consequently provides a significantly greater depth of cement penetration than other commonly used irrigating agents. It was noted that cement penetration into cancellous bone followed the line and depth of cleaning from lavage. In conclusion, the hypothesis can be accepted, and lavage with a detergent solution affords a statistically greater depth of cement penetration into bone than that of the universally used 0.9% saline lavage

A strong clinical impression exists that joint lavage often provides symptomatic relief for painful osteoarthritis of the knee. A controlled trial was conducted to test this hypothesis. A group of 37 painful osteoarthritic knees were treated by arthroscopic lavage and physiotherapy, and a control group of 24 knees were treated by physiotherapy alone. There was better relief of pain in the lavage group, and the effect was still present at one year. An improvement in the signs of inflammation lasted for about three months. Pain was relieved more effectively in patients with slight radiographic changes than in those with advanced changes. Our results confirm the effectiveness of joint lavage in the management of painful osteoarthritis of the knee

Aims: The aim of the study was to determine the efþcacy of jet lavage in comparison to syringe lavage with respect to cement penetration and stability of the poly-ethylene patellar component after patellar resurfacing in total knee arthroplasty. Methods: In a cadaver study, we prepared 37 fresh frozen human patella pairs. The retropatellar bed was randomly cleaned with either jet lavage or a bladder syringe. The polyethylene component was cemented using Palacos R. For 12 patella pairs, sagittal sections were obtained at predeþned levels using a diamond saw. Mikroradiograms were digitised and analysed with respect to cement penetration. For the remaining 25 patella pairs, pullout tests were performed on patellar components using a traction-compression device. Results: Cement penetration was signiþcantly greater (P< 0.0001) in the jet lavage specimens compared to the syringe lavage specimens. The maximum force required to cause mechanical failure was signiþcantly greater (P< 0,0001) in jet lavage specimens compared to syringe lavage specimens. Conclusions: Our results support the routine use of jet lavage for cleansing the patellar bed prior to cement application in cemented patellar resurfacing

Arthroscopic lavage is commonly used in the management of mild to moderate arthritis of the knee. In the last few years the use of Hyaluronic Acid and its derivatives has become popular in the management of this same group of patients. The study was set up to establish whether Synvisc (HylanGF-20) produced equivalent or improved symptomatic relief when compared to arthroscopic lavage. A prospective randomised trial. Fifty patients with knee OA were randomly allocated to either the arthroscopic lavage or Synvisc group. All patients were assessed prior to treatment using the WOMAC knee evaluation questionnaire, and further assessments were made at 6 weeks, 3 months, 6 months and one year post treatment. The Synvisc group showed greater and more consistent improvement in WOMAC scores than the lavage group at all assessments post treatment. The difference between the treatment groups was statistically significant at 6 months (p< 0. 05) and at 1 Year (p=0. 0018). We conclude that a course of Synvisc injections can be administered on an out-patient basis and is a safer, more cost-effective and more reliable treatment for Knee OA compared to arthroscopic lavage

This paper suggests that bone-cement interlocking is superior when the cut surfaces of the bone have been prepared using pulsed lavage with saline prior to application of cement and the prostheses during total knee joint arthroplasty. The aim is to put the case forward for the inclusion of the question whether or not pulsed lavage was used on the National Joint Register questionnaire. This will then in course give guidance as to whether there is an improved outcome when pulsed lavage was used or whether it is a waste of resources. Review of the 6-month postoperative films of the total knee joint replacements of two senior surgeons was carried out in 1996. Both surgeons use the Genesis total knee system. Surgeon 1 uses pulsed lavage routinely, and surgeon 2 does not. This is the only difference in their techniques. There have been no early aseptic failures in either group at 5 years. A lucent line was consistently seen between the bone-cement interface when pulsed lavage was used. Furthermore, the depth of the cement mantle on the tibia was greater in the pulsed lavage group. We suggest that the use of pulsed lavage at the preparation of the cut bone surfaces before the application of the cement and prostheses improves the bone-cement interface. The significance of this finding is uncertain, but a case can be made for this question to be included in the National Joint Register questionnaire

Accepted treatment for acute septic arthritis in children involves drainage of the pus and systematic antibiotics. Review of published studies show that there is a tendency for paediatricians and physicians to drain pus by aspiration and for surgeons to drain the pus by arthrotomy and surgical lavage. There is however no published prospective study comparing the two methods of drainage. 201 consecutive children under 13 (134 boys and 67 girls) presenting to our hospital with acute septic arthritis were entered into a prospective study and randomised to either aspiration of the joint with a 14g needle or arthrotomy and lavage. Both groups had systematic antibiotics for six weeks. All patients were followed up with clinical examination and x-rays at 2, 6, 12, 24 and 52 weeks. There were 102 patients in the aspiration group and 99 in the lavage group. Both groups were similar in respect to mean age (2 yrs 5m and 2 yrs 10m respectively) and both groups had had symptoms for a mean of 6. 5 days. The commonest joint involved in both groups was the knee, followed by the shoulder, and the commonest organism involved was salmonella, followed by staphylococcus aureus. Aspiration failed in 9/102 patients who then underwent arthrotomy. Aspirated cases were discharged at a mean of 7. 9 days compared to 9. 8 days in the lavage group. There is no published method of measuring clinical improvement in septic arthritis so we devised the Blantyre septic joint score (BSJS) which measures pain, swelling, range of motion and function. Using the BSJS we found significant difference in scores between the aspirated and the lavage groups at any stage of follow up. We could not demonstrate any difference in clinical outcome between aspiration and arthrotomy with lavage in the treatment of septic arthritis

We randomised 24 patients before they had a cemented hemiarthroplasty for hip fracture to receive either thorough or minimal saline lavage of the femoral canal. We then determined the effect in each group on the thromboembolic and cardiopulmonary responses to the pressurised insertion of cement, using transoesophageal echocardiography to show the echogenic embolic response. We found a statistically significant reduction in both the duration of the response and the number of large emboli in patients who had had thorough lavage as compared with the control group with minimal lavage. There was also less disturbance of pulmonary function, as assessed by the change in end-tidal CO2 levels and oxygen saturation, in patients who had thorough lavage. Three patients had a significant fall in blood pressure during cement insertion; all had only minimal lavage. We consider that thorough lavage should be an essential part of the preparation of the proximal femur before cement insertion

For degenerative osteoarthritis of the knees, a variety of non-surgical management options have been tried from time to time. Medical management, chondroprotective agents, disease modifying drugs, viscosupplimentation etc. to name a few. Arthroscopic knee lavage with saline also has shown good results, with the effect of cleaning the debries from the joint. Growth Factors Rich Plasma (GFRP) or Platelet Rich Plasma (PRP) is an emerging treatment therapy called “ Orthobiologics”. Alfa granules in platelets contain numerous growth factors which enhance tissue recovery dramatically by catalyzing the body's natural healing response. PRP also attracts Mesenchymal Stem Cells, which differentiate into variety of cell types during tissue repair processes & induce the production of new collagen by the fibroblasts, osteoblasts and chondrocytes as per the need of the parent tissue. Knee lavage is done under local anesthesia using single antero-lateral portal. Four liters of saline is used to lavage the knee and at the end of procedure 80 mg. methyl prednisolone is injected. For GFRP injection, 100 cc of patient's blood is double centrifuged in the refrigerated blood component separator centrifuge in the blood bank giving about 15 cc of buffy layer having GFRP. Since Feb. 2010, more than 1000 knees of different grades of osteoarthritis have been injected with GFRP and the results compared with other different treatment options. Results of few different combination therapies are presented in this study. 1. Knee Lavage Vs Autologous GFRP Injection (100+100 cases) 2. Knee Lavage + Autologous GFRP Injection in 1 knee Vs GFRP Injection only in other knee (200+200 Knees) 3. Visco-supplimentation Vs Autologous GFRP Injection. (10+10cases). Results were analyzed up to 1 year as per VAS scale. Knee Lavage clears the joint of the microscopic and macroscopic debris of the cartilage and synovium which are causing chemical and mechanical irritation resulting in the inflammatory cascade. GFRP injection tries to repair the cartilage by the efficacy of the Growth factors contained therein. It has been observed that Knee Lavage and GFRP Injection have almost similar efficacy at 1 year, though knee lavage starts showing its effects early. GFRP therapy has shown better results compared to visco supplimentation at 1 year. Combination of knee lavage with GFRP injection showed much better results than GFRP injection alone and the results are inversely related to the grade of the osteoarthritis. Viscosupplimentation has very short lived efficacy. It's concluded that Knee Lavage followed by GFRP injection gives the best long term results and this pilot project initiated, hopefully will go a long way in future to change the course of the management for osteoarthritis knees at a minimal cost and may obviate the need for Knee arthroplasty if started in early stages of Osteoartrhritis

Elderly patients are at risk of developing cardiopulmonary and cognitive impairment following major orthopaedic surgery. One of the mechanisms believed to be responsible for such complications after total knee arthroplasty (TKA) is the release of embolic debris that may travel from the surgical site, through the lungs, and into the brain following tourniquet release. Removal of fat globules and marrow particulates from bone surfaces prior to pressurization and cementation of prosthetic components may reduce the number and size of embolic particles. We conducted a prospective, randomized clinical trial to compare the effect of carbon dioxide (CO2) gas versus saline lavage on the number and size of embolic particles observed during cemented TKA. Twenty patients undergoing elective TKA were randomly assigned to one of two groups. In group A, standard high-pressure pulsatile saline lavage was used to clean the resected bone surfaces. In group B, the femoral canal was cleaned using CO2 lavage techniques and the resected bone surfaces were cleaned with a manual saline wash followed by CO2 lavage. All patients received the same TKA implant design. The presence of embolic particles in the heart and brain was intraoperatively monitored using transesophageal echocardiography (TEE) and transcranial Doppler (TCD) techniques, respectively. For each patient, TEE images were analyzed at tourniquet release and during the final range of motion (ROM) assessment prior to wound closure using the following five point cardiac echogenic scoring system: Grade 0: no emboli; Grade I: a few fine emboli; Grade II: a cascade of many fine emboli; Grade III: a cascade of fine emboli mixed with at least one embolus > 1 cm in diameter; and Grade IV: large embolic masses > 3 cm in diameter. The highest grade observed during either tourniquet release or ROM assessment was assigned to each patient. Cardiac emboli were then categorized according to embolic grade as follows: Grade 0 or I = Low; Grade II, III, or IV = High. For analysis of cerebral emboli, the total number of positive counts measured using TCD was recorded for each patient. TEE data were available for nine patients in group A and eight patients in group B. Comparative TCD data were available for seven patients in group A and six patients in group B. Fischer’s Exact Test was used to check for differences between groups. For cardiac emboli, nine of nine (100%) patients in group A were in the High category based on their TEE grade, with eight patients being Grade II and one Grade III. In contrast, three of eight (37.5%) patients in group B were in the Low category, leaving only five (62.5%) in the High category (p = 0.08). All five group B patients in the High category were Grade II. No patients in group A had cerebral emboli detected using TCD. In group B, three of six patients had one cerebral embolus and the remaining three had none. Three patients in group B were excluded from the comparative TCD analysis due to the presence of a patent foramen ovale (PFO). These three patients with a PFO had one, three, and four cerebral emboli, respectively. No patients in group A had a PFO. This study examines the effect of pulsatile saline versus CO2 gas lavage on intraoperative embolic events during TKA. Thirty-seven percent of patients in the CO2 lavage group had a Low cardiac echogenic score compared with 0% of patients in the standard pulsatile saline lavage group. A single cerebral embolus was detected in three of six patients in the CO2 lavage group compared with none in the seven patients in the standard pulsatile saline lavage group. Compared to published studies on cerebral emboli in TKA, the overall incidence of cerebral emboli in the current study was very low across both groups. The results of this study suggest that CO2 gas, as compared to pulsatile saline, lavage reduces the number of intraoperative cardiac emboli during total knee arthroplasty

We measured the effect of arthroscopic lavage and debridement of the osteoarthritic knee by comparing objective measurements of thigh muscle function before and after operation. There was some improvement in quadriceps isokinetic torque at six and 12 weeks after joint lavage but not after debridement. Neither method significantly relieved the patients' symptoms

The purpose of this randomized controlled trial is to evaluate the efficacy of using dilute betadine versus sterile saline lavage in aseptic revision total knee (TKA) and hip (THA) arthroplasty to prevent acute postoperative deep periprosthetic joint infection (PJI). Of the 450 patients that were randomized, 5 did not have 90-day follow-up, 9 did not receive the correct treatment, and 4 were excluded for intraoperative findings consistent with PJI. 221 Patients (144 knees and 77 hips) received saline lavage only and 211 (136 knees and 75 hips) received a three-minute dilute betadine lavage (0.35%) prior to wound closure. Patients were observed for the incidence of acute postoperative deep PJI within 90 days of surgery. Statistical analysis was performed using t-tests or Fisher's exact test where appropriate. Power analysis determined that 285 patients per group are needed to detect a reduction in the rate of PJI from 5% to 1% (alpha=0.05, beta=0.20). There were seven PJIs in the saline group and one in the betadine lavage group (3.2% vs. 0.5%, p=0.068). There were no significant differences in any baseline demographics between groups suggesting appropriate randomization. Although we believe the observed difference between treatments is clinically relevant, it was not statistically significant with the sample size enrolled thus far and enrollment is ongoing. Nonetheless, we believe that these data suggests that dilute betadine lavage is a simple method to reduce the rate of acute postoperative PJI in patients undergoing aseptic revision procedures

We modelled a 'clean' surgical wound lightly contaminated with airborne bacteria, using agar, ovine muscle and ovine adipose tissue. This was used to assess the effect on bacteria of ultraviolet C light (UVC) 1200 mu W/cm2, hydrogen peroxide 3%, povidone-iodine 1% and 10%, chlorhexidine 0.05%, pulsed jet lavage with UVC and syringe and needle lavage with chlorhexidine 0.05%. All the agents were effective on agar, but mixing with blood or plasma neutralised hydrogen peroxide and povidone-iodine 1%. All the agents were less effective on tissue specimens than on agar, but were more effective on adipose tissue than on muscle. All the antiseptics except chlorhexidine were less effective when blood or plasma was added to muscle specimens before disinfection. UVC after pulsed jet lavage had an additive effect. Syringe and needle lavage with chlorhexidine 0.05% was the most effective method tested; it reduced colony counts by 99.8% and warrants clinical investigation

In August 2007 NICE issued its guidance for the treatment of patients with knee osteoarthritis (OA) with arthroscopic lavage. The recommendations stated that referral for arthroscopic lavage and debridement should not be offered as part of treatment for osteoarthritis, unless the person has osteoarthritis with a clear history of ‘mechanical locking’ (not gelling, giving way, or x-ray evidence of loose bodies). The aim of this study was to assess both the application of these guidelines over a four month period and whether this procedure had improved symptoms at first follow-up. This was a retrospective review from August-December 2011. The total number of arthroscopies performed during this period was obtained from theatre records. Further data was obtained through the hospital's electronic database. The diagnosis of OA was made through the analysis of referral and clinic letters, plain radiographs, MRI reports and operation notes. Only those patients with persisting OA symptoms were included, those with OA and recent history of injury or trauma were excluded. During this time period, 222 knee arthroscopies were performed in total, 99 were identified with persistent OA symptoms. Having identified these patients, referral letters were further analysed to identify the initial presenting symptom. Of the 99, 50 presented with pain, 28 presented with pain plus another symptom other than locking e.g. stiffness/swelling/giving-way, 21 presented with pain plus mechanical locking. According to current guidelines only these 21 patients should have been offered arthroscopic lavage as a form of treatment. In addition to these findings we identified what procedures had been carried out during arthroscopy for each symptom. Of those presenting with pain, 82% had a washout and debridement, 8% had washout, 4% had partial medial meniscectomy, 4% had lateral patellar release and 2% had partial lateral meniscectomy. Those with pain plus other symptoms not including locking, 82% had washout and debridement, 11% had partial medial meniscectomy, and 7% had a washout. Of those presenting with pain plus mechanical locking, 81% had washout and debridement and 19% had partial medial meniscectomy. Following the procedure, we analysed the outcome of symptoms at first-follow up. The mean follow-up time was 8 weeks. Of those presenting with just pain, 44% showed improvement, 52% had no change/on-going symptoms, 2% were unknown. Of those with pain plus other symptoms other than locking, 57% showed improvement, 35% had no change/on-going symptoms, 8% unknown. Of those with pain plus mechanical locking, 80% showed improvement, 10% had no change/on-going symptoms, 10% unknown. The results of this study support the current evidence that unless there are clear mechanical symptoms of locking, the use of arthroscopy in arthritic knee joints should be judicious and the reasons should be clearly documented

The optimal choice of irrigating solution or irrigating pressure in the initial management of open fracture wounds remains controversial. FLOW compared the effect of castile soap versus normal saline, and low versus high pressure pulsatile lavage on one year re-operation rates in patients with open fracture wounds. We conducted a multicentre, blinded, two-by-two factorial, pilot randomised trial of 111 patients with open fracture wounds receiving either castile soap solution or normal saline and either high or low pressure pulsatile lavage. The primary outcome, re-operation within one year, included infections, wound healing problems, and nonunions. Secondary outcomes included all operative and non-operative infections, wound healing problems, nonunion and functional outcomes. We followed the intention to treat principle. Eighty-nine patients (80.2%) completed the 12-month follow-up. As anticipated in this small-sample-size pilot study, results were compatible with substantial benefit and substantial harm. The hazard ratio (HR) for re-operation with castile soap was 0.77 (95% Confidence Interval (CI) 0.35 to 1.69, p=0.52). With low pressure lavage, the hazard ratio for the risk of re-operation was 0.56, 95% CI 0.25 to 1.27, p=0.17. Secondary outcomes showed a significant relative risk reduction for nonunion of 63% in favour of castile soap (p=0.036), and a trend for a relative risk reduction for nonunion of 44% in favour of low pressure lavage (p=0.22). Functional outcome scores showed no significant differences at any time point between groups. The FLOW pilot randomised controlled trial demonstrated the possibility that the use of low pressure may decrease the re-operation rate for infection, wound healing problems, or nonunion. Our findings provide compelling rationale for continued investigation in a pivotal FLOW trial of 2280 patients