# Does Pressurized Carbon Dioxide Lavage Improve Bone Cleaning in Cemented Arthroplasty?
###### Abstract  
Cemented implant fixation in total joint arthroplasty has been proven to be safe and reliable with good long-term results. However, aseptic loosening is one of the main reasons for revision, potentially caused by poor cementation with low penetration depth in the cancellous bone. Aim of this prospective laboratory study was, to compare impact pressure and cleaning effects of pulsatile saline lavage to novel carbon dioxide lavage in a standardized carbon foam setup, to determine whether or not additional use of carbon dioxide lavage has any impact on cleaning volume or cleaning depth in cancellous bone. Carbon specimens simulating human cancellous bone were filled with industrial grease and then underwent a standardized cleaning procedure. Specimens underwent computed tomography pre- and post-cleaning. Regarding the impact pressure, isolated carbon dioxide lavage showed significant lower pressure compared to pulsatile saline lavage. Even though the combination of carbon dioxide lavage and pulsatile saline lavage had a positive cleaning effect compared to the isolated use of pulsatile saline lavage or carbon dioxide lavage, this was not significant in terms of cleaning volume or cleaning depth. carbon dioxide lavage; pulsatile lavage; joint arthroplasty; bone preparation; cement; total knee arthroplasty; total hip arthroplasty  
Received: 20 March 2021  
Accepted: 26 June 2021  
Submitted: 30 June 2021  
Dues Pressurized Carbon Dioxide Lavage Improve Bone Cleaning in Cemented Arthroplasty? Cemented implant fixation in total joint arthroplasty has demonstrated to be a reliable and safe procedure with excellent long-term results [1; 2; 3; 4]. However, there are many regional differences if cemented or non-cemented fixation is performed. Regarding cemented fixation in total hip arthroplasty, those differences vary from 76% (Sweden) to 29% (Denmark) [5]. National registries demonstrate slight differences in the technique for total knee arthroplasty as well. In Germany, the Netherlands and New Zealand, 95% and more of total knee arthrolasties are performed using the cemented technique [6; 7; 8], whereas in Sweden it was only 92% in 2019 [9]. Despite regional differences in the choice of technique, the procedure for cemented arthroplasty is standardized. In total knee arthroplasty this includes to use high-pressure pulsatile saline lavage irrigation, drilling holes into the tibia, drying the bone and applying vacuum-mixed-cement to both, implant and bone [10]. In total hip arthroplasty third generation cementing technique is performed. This includes preparing bone bed properly by aggressive rasping, using high-pressure pulsatile saline lavage irrigation, using a distal cement restriction, applying vacuum-mixed-cement in retrograde technique into the femurvia cement gun, pressurizing the cement and inserting the stem with a distal centralizer [11]. Despite improved technique of cementing, aseptic loosening is still the main reason for revision after cemented total knee and hip arthroplasty [6; 12; 13]. Implant stability can be increased by adequate cleaning of the bone bed prior to cement application. In addition, pulsatile lavage can have a protective effect on implant stability in case of reduced bone density [14]. This preparation requires removal of bone marrow containing residual bone material, blood and fat. Even the presence of blood between bone and cement can reduce integrity of bone-cement interface [15]. Bone cement interface and penetration depth of cement are directly related to prior cleaning. For stable anchorage, desired cement thickness is described as 2-5 mm [16; 17]. With this cement penetration depth, implant failure rates are significantly lower compared to cement thickness below 2 mm [18]. In addition, harmful thermal effects of polymerizing cement are not observed, which are described for a cement thickness of more than 5 mm [19; 20].