Abstract
Increased intramedullary pressure in the femoral cavity causes intravasation of bone marrow content to the circulation which may lead to occlusion of pulmonary vessels and cardiorespiratory dysfunction. A one-step reamer-irrigator-aspirator (RIA) technique has been developed to reduce the intramedullary pressure (IMP) during the reaming procedure. This study was design to compare IMP with a standard reaming technique with IMP during reaming with the RIA system with a hypothesis that the RIA system would involve lower pressures. In a randomised study in 19 Norwegian landrace pigs reamed intramedullary nailing was performed with two different reamer devices. Nine animals were operated with a traditional reamer and 10 animals with RIA. One animal in the RIA group was excluded due to a perioperative femoral fracture, and three animals in the traditional group were excluded due to a perforation of the distal medial femoral cortex. The intramedullary pressure was registrated with a transducer-tipped pressure monitoring catheter during reaming. There was a significantly higher intramedullary pressure (P<0.05) during reaming in the traditional reamer group (mean 188+/-38 mmHg) than in the RIA group (mean 33+/-8 mmHg). Intramedullary pressures recorded before surgery, at the opening of the femoral cavity with an awl, by insertion of a guide wire, at insertion of the intramedullary nail, and 10 min after nail insertion showed no significant differences between the groups. The use of a one-step reamer-irrigator-aspirator technique in the pig femur induced less intramedullary pressure increase than the use of a traditional reamer.
Highlights
EVOLUTION IN ORTHOPEDIC TRAUMA TREATMENT Until the 1970s, initial treatment of fractures in polytraumatized patients was conservative, as the patients were considered physiological unstable and the operative treatment regarded as a high-risk procedure
The aims of the present studies were: 1. to compare the procedure-related effects of intramedullary reaming with the reamer irrigator aspirator (RIA) system with a traditional reaming (TR) system in an experimental model and 2. to explore the additional procedure-related effect of reamed intramedullary nailing (IMN) in severely traumatized patients In Paper I we evaluated the intramedullary pressure (IMP) increase during reaming with the RIA and the TR technique
A transient cardiopulmonary response related to IMN was demonstrated
Summary
EVOLUTION IN ORTHOPEDIC TRAUMA TREATMENT Until the 1970s, initial treatment of fractures in polytraumatized patients was conservative, as the patients were considered physiological unstable and the operative treatment regarded as a high-risk procedure. Operative treatment of long bone fractures in severely injured patients was demonstrated to decrease mortality and morbidity, in particular the pulmonary related morbidity. A modification of the principle of “early total care” was allocated in severely injured, hemodynamically instable patients, who were not expected to tolerate the extent of surgery caused by internal major fracture stabilization In these patients the concept of “damage control orthopedics” was applied; initial bleeding control, hemodynamical stabilization, and external fixation of major instable fractures, with secondary internal fracture stabilization in a stable situation. This study was initiated to evaluate the impact of primary femoral IMN on coagulation-, fibrinolysis-, inflammatory- and cardiopulmonary responses in polytraumatized patients. Conclusion: In the polytraumatized patients with femoral shaft fractures operated with primary IMN we observed a substantial response related to the initial trauma. Delayed arterial TNF-α, IL-6 and IL10 peak levels were observed, and it could be questioned whether these were related to the procedure
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