CEMAL KURAL, İbrahim KAYA, Murat YILMAZ, Emrah DEMİRBAŞ, Barış YÜCEL, Musa KORKMAZ, M. Ercan ÇETİNKUS

Kirletilmiş dana spongiöz kemiğinin debridmanında üç yıkama yönteminin karşılaştırılması ve yıkama süresinin debridman üzerine etkisi

Amaç: Açık kırıklarda yıkama ve debridman, tedavinin önemli bir bölümünü oluşturur. Bu çalışmada, farklı yıkama yöntemlerinin ve farklı sürelerde yıkamanın kirletilmiş sığır femur spongiöz kemik örneklerinin temizlenmesindeki etkin- liği ve yıkamaya bağlı oluşabilecek kemik hasarı araştırıldı. Çalışma planı: Taze donmuş sığır distal femurundan 4x4x1 cm boyutlarında 72 adet spongiöz kemik örneği alındı ve her bir örneğin üst yüzeyi 2 mm derinliğinde oyularak eşit büyüklükte dört kare oluşturuldu. Bütün kemikler aynı yöntem kullanılarak inşaat kumu ile kirletildi. Örneklerden rastgele seçimle 24 adet- lik üç grup oluşturuldu. Bir gruba 20 ml’lik plastik şırınga ile yıkama uygulanırken, bir gruba düşük basınçlı (DBY), bir gru- ba yüksek basınçlı (YBY) yıkama uygulandı. Yıkama her bir gruptaki sekizer örneğe farklı sürelerde (3, 6 ve 9 dakika) uygu- landı. Yıkama işleminden sonra kemik örneklerinin görüntüle- ri video-mikroskop kamera ile bilgisayar ekranına aktarılarak üzerinde kalan kum tanecikleri sayıldı ve yıkama sonrası ke- mikte oluşan makroskobik doku hasarı değerlendirildi. Sonuçlar: Yüksek basınçlı yıkama uygulanan örneklerde, diğer iki yönteme göre anlamlı derecede düşük sayıda kum taneciği bulundu (p0.05). Yıkama sonucu kemikte en az doku hasarı 3 dk’lık yıkamada DBY yönteminde görüldü (p0.05). Çıkarımlar: Bulgularımız, kum taneciklerinin temizlenme- sinde en etkili yöntemin YBY olduğunu ve yıkama süresini artırmanın ek yarar sağlamadığını; ancak, YBY yönteminin 3 dakikalık yıkamada kemik dokusuna en fazla zarar veren yöntem olduğunu göstermiştir.

Anahtar Kelimeler:

Karşılaştırmalı çalışma, Modeller, hayvan, Debridman, Terapötik irigasyon, Yara enfeksiyonu, Kemik hastalıkları, Sığır

A comparison between three irrigation methods in the debridement of contaminated bovine cancellous bone and the effect of duration of irrigation on the efﬁciency of debridement

Objectives: Irrigation and debridement constitute an important part of treatment of open fractures. We investigated the efﬁ- ciency of different irrigation methods and durations in cleansing contaminated bovine femur cancellous bone samples and the extent of tissue damage associated with irrigation. Methods: A total of 72 samples of 4x4x1 cm size were obtained from fresh frozen bovine distal femoral cancellous bone. The top surface of the samples were sawed to a 2-mm depth to cre- ate four squares equal in size. All the samples were contami- nated with construction sand using the same method and were then randomized to three irrigation groups (bulb syringe irriga- tion, high-pressure pulsatile lavage, and low-pressure pulsatile lavage), each consisting of 24 samples. The duration of irriga- tion was set as 3, 6, or 9 minutes for every eight samples of each group. After the irrigation procedure, the images were trans- ferred to a computer screen with a video-microscope camera and the number of sand particles on the samples were counted and irrigation-related macroscopic bone damage was assessed. Results: The lowest number of sand particles was found on the samples irrigated by high-pressure pulsatile lavage (p<0.001). The duration of irrigation did not affect the efﬁciency of cleansing in all the groups (p>0.05). The least irrigation-related bone dam- age was observed in samples irrigated by low-pressure pulsatile lavage for 3 minutes (p<0.01). The amount of bone damage was similar in all groups after irrigations beyond 3 minutes (p>0.05). Conclusion: Our ﬁndings showed that the most efﬁcient method of cleansing contaminated bone samples was high-pressure pul- satile lavage and that prolonged irrigations did not enhance the efﬁciency of the irrigation method; however, high-pressure irriga- tion of 3 minute duration resulted in the greatest bone damage.

Keywords:

Comparative Study, Models, Animal, Debridement, Therapeutic Irrigation, Wound Infection, Bone Diseases, Cattle,

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1. Behrens FF, Liporace F, Sirkin M. Fractures with soft tissue injuries. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C, editors. Skeletal trauma: basic science, management, and reconstruction. 4th ed. Philadelphia: Saunders Elsevier; 2009. p. 367-82.
2. Gustillo RB. Management of open fractures and their complications. Philadelphia: W. B. Saunders, 1982.
3. Sanders R, Swiontkowski M, Nunley J, Spiegel P. The management of fractures with soft-tissue disruptions. J Bone Joint Surg [Am] 1993;75:778-89.
4. Bhaskar SN, Cutright DE, Gross A. Effect of water lavage on infected wounds in the rat. J Periodontol 1969;40:671-2.
5. Brown LL, Shelton HT, Bornside GH, Cohn I Jr. Evaluation of wound irrigation by pulsatile jet and conventional methods. Ann Surg 1978;187:170-3.
6. Gross A, Bhaskar SN, Cutright DE, Beasley JD 3rd, Perez B. The effect of pulsating water jet lavage on experimental contaminated wounds. J Oral Surg 1971;29:187-90.
7. Rodeheaver GT, Pettry D, Thacker JG, Edgerton MT, Edlich RF. Wound cleansing by high pressure irrigation. Surg Gynecol Obstet 1975;141:357-62.
8. Wheeler CB, Rodeheaver GT, Thacker JG, Edgerton MT, Edilich RF. Side-effects of high pressure irrigation. Surg Gynecol Obstet 1976;143:775-8.
9. Sobel JW, Goldberg VM. Pulsatile irrigation in orthopedics. Orthopedics 1985;8:1019-22.
10. Bhandari M, Adili A, Lachowski RJ. High pressure pulsatile lavage of contaminated human tibiae: an in vitro study. J Orthop Trauma 1998;12:479-84.
11. Draeger RW, Dirschl DR, Dahners LE. Debridement of cancellous bone: a comparison of irrigation methods. J Orthop Trauma 2006;20:692-8.
12. Lee EW, Dirschl DR, Duff G, Dahners LE, Miclau T. High-pressure pulsatile lavage irrigation of fresh intraarticular fractures: effectiveness at removing particulate matter from bone. J Orthop Trauma 2002;16:162-5.
13. Draeger RW, Dahners LE. Traumatic wound debridement: a comparison of irrigation methods. J Orthop Trauma 2006;20:83-8.
14. Esterhai JL Jr, Queenan J. Management of soft tissue wounds associated with type III open fractures. Orthop Clin North Am 1991;22:427-32.
15. Ger R. The management of open fracture of the tibia with skin loss. J Trauma 1970;10:112-21.
16. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg [Am] 1990;72:299-304.
17. O’Meara PM. Management of open fractures. Orthop Rev 1992;21:1177-85.
18. Dirschl DR, Wilson FC. Topical antibiotic irrigation in the prophylaxis of operative wound infections in orthopedic surgery. Orthop Clin North Am 1991;22:419-26.
19. Edlich RF, Custer J, Madden J, Dajani AS, Rogers W, Wangensteen OH. Studies in management of the contaminated wound. 3. Assessment of the effectiveness of irrigation with antiseptic agents. Am J Surg 1969;118:21-30.
20. Wood GW. General principles of fracture treatment. In: Canale ST, Beaty JH, editors. Campbell’s operative orthopaedics. 11th ed. Philadelphia: Mosby Elsevier; 2007. p. 3035-9.
21. Hassinger SM, Harding G, Wongworawat MD. High-pressure pulsatile lavage propagates bacteria into soft tissue.Clin Orthop Relat Res 2005;(439):27-31.
22. Pronchik D, Barber C, Rittenhouse S. Low- versus highpressure irrigation techniques in Staphylococcus aureusinoculated wounds. Am J Emerg Med 1999;17:121-4.
23. Bhaskar SN, Cutright DE, Runsuck EE, Gross A. Pulsating water jet devices in debridement of combat wounds. Mil Med 1971;136:264-6.
24. Hamer ML, Robson MC, Krizek TJ, Southwick WO. Quantitative bacterial analysis of comparative wound irrigations. Ann Surg 1975;181:819-22.
25. McDonald WS, Nichter LS. Debridement of bacterial and particulate-contaminated wounds. Ann Plast Surg 1994;33:142-7.
26. Svoboda SJ, Bice TG, Gooden HA, Brooks DE, Thomas DB, Wenke JC. Comparison of bulb syringe and pulsed lavage irrigation with use of a bioluminescent musculoskeletal wound model. J Bone Joint Surg [Am] 2006;88:2167-74.
27. Hirn MY, Salmela PM, Vuento RE. High-pressure saline washing of allografts reduces bacterial contamination. Acta Orthop Scand 2001;72:83-5.
28. Majkowski RS, Miles AW, Bannister GC, Perkins J, Taylor GJ. Bone surface preparation in cemented joint replacement. J Bone Joint Surg [Br] 1993;75:459-63.
29. Luedtke-Hoffmann KA, Schafer DS. Pulsed lavage in wound cleansing. Phys Ther 2000;80:292-300.
30. Saxe A, Goldstein E, Dixon S, Ostrup R. Pulsatile lavage in the management of postoperative wound infections. Am Surg 1980;46:391-7.
31. Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. High and low pressure pulsatile lavage of contaminated tibial fractures: an in vitro study of bacterial adherence and bone damage. J Orthop Trauma 1999; 13:526-33.
32. Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. High pressure pulsatile lavage irrigation of intraarticular fractures: effects on fracture healing. J Orthop Trauma 1998;12:460-3.
33. Boyd JI 3rd, Wongworawat MD. High-pressure pulsatile lavage causes soft tissue damage. Clin Orthop Relat Res 2004;(427):13-7.
34. Polzin B, Ellis T, Dirschl DR. Effects of varying pulsatile lavage pressure on cancellous bone structure and fracture healing. J Orthop Trauma 2006;20:261-6.