Reamer-irrigator-aspirator Group Research Articles

Reamer Irrigator Aspirator Versus Iliac Crest Bone Grafting and Proximal Tibial Curettage: Is There a Difference in Blood Loss and Transfusion Rates?

To compare blood loss and transfusion rates among reamer irrigator aspirator (RIA), iliac crest bone graft (ICBG), and proximal tibial curettage (PTC) for autograft harvest. Retrospective comparative study. Level 1 trauma center. The study included 139 adult patients treated between 2011 and 2018. Nonunion repair of the femur or tibia using either RIA (n = 64), ICBG (n = 59), or PTC (n = 16) for autograft. Estimated blood loss and transfusion rates. Patient demographics, surgical indications, and medical comorbidities that affect bleeding did not differ among the groups. Estimated blood loss (mL) was significantly higher in the RIA group [RIA: 388 ± 368 (50-2000), ICBG: 286 ± 344 (10-2000), PTC: 196 mL ± 219 (10-700), P < 0.01]. The transfusion rate was also significantly higher in the RIA group (RIA 14%, ICBG 0%, PTC 0%, P < 0.01). The amount of graft obtained was higher in the RIA group (RIA = 48.3 mL, ICBG = 31.0 mL, PTC = 18.8 mL, P < 0.01), and the operative time (hours) was longer in the RIA group (RIA = 2.8, ICBG = 2.6, PTC = 1.9, P = 0.04). Estimated blood loss and transfusion rates were significantly higher in patients undergoing RIA compared with those in patients undergoing ICBG and PTC; however, the incidence of transfusion after RIA (14%) was considerably lower than previous reports. These findings suggest that the risk of transfusion after RIA is present and clinically significant but lower than previously believed, and it is likely affected by the amount of graft obtained and complexity of the nonunion repair. The risk of transfusion should be discussed with patients and the choice of RIA carefully evaluated in patients who have anemia or risk factors of bleeding. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary reaming modality for management of postoperative long bone infection: a prospective randomized controlled trial in 44 patients

BackgroundStudies addressing the management of intramedullary infection are mainly retrospective and with a limited number of cases. Reaming can be performed using either conventional reaming or using the reamer/irrigator/aspirator (RIA) system. Until now there have been no comparative prospective studies between these two methods. We aimed to compare the efficacy of RIA with conventional reaming followed by insertion of antibiotic-loaded cement, for the treatment of intramedullary nail infection of long bones. We assessed the rate of remission between groups after two-year follow-up and identified microorganisms using tissue cultures and sonication of explanted intramedullary nail (IMN).MethodsA noninferiority, randomized clinical trial was carried out between August 2013 and August 2015 involving 44 patients of whom a locked IMN implant of the femur and/or tibia was retrieved and who all met the clinical and radiological criteria for IMN-associated osteomyelitis. Patients were randomized into two groups: RIA alone versus conventional reaming followed by antibiotic-loaded cement insertion. Both groups also underwent six-weeks of antibiotic treatment according to the results of the antibiogram. Patients were evaluated after 1, 3, 6, 12 and 24 months for radiological and clinical follow-up.ResultsAfter 24 months, the rate of infection remission was similar between the two groups, 87% in the RIA group and 95.5% in the conventional reaming group (p = 0.60). Among four patients who had recurrence of infection, the time to reappearance of symptoms varied from 20 days to twenty-two months. Staphylococcus aureus and coagulase-negative Staphylococci were isolated in 23 (40.4%) and 13 (22.9%) patients, respectively. Interestingly, we identified 20% (9/45) of polymicrobial infection.ConclusionThis study concludes that the RIA system alone, is noninferior to conventional reaming followed by antibiotic cement spacer in the treatment of IMN infection. However, RIA shows greater efficacy in the collection of infected medullary bone tissue, mainly in cases of infected retrograde nail of the femur.Trial registrationISRCTN82233198. Retroactively registered on July 29, 2019.

Prospective Randomized Clinical Trial Investigating the Effect of the Reamer-Irrigator-Aspirator on the Volume of Embolic Load and Respiratory Function During Intramedullary Nailing of Femoral Shaft Fractures.

We sought to determine whether the use of the Reamer-Irrigator-Aspirator (RIA) device resulted in a decreased amount of fat emboli compared with standard reaming (SR) when performing intramedullary (IM) nailing of femoral shaft fractures. Prospective randomized clinical trial. Multi-centered trial, level I trauma centers. All eligible patients who presented to participating institutions with an isolated femoral shaft fracture amenable to fixation with antegrade IM nailing. Thirty-one patients were enrolled: nine were excluded because of technical difficulties with the transesophageal echocardiogram (TEE) recording. Therefore, the study comprised 22 patients: 11 patients randomized to the SR group and eleven patients randomized to the RIA group. Antegrade IM nailing of a femoral shaft fracture with standard reamers or the RIA device. All patients were monitored intraoperatively with a continuous TEE to assess embolic events in the right atrium. A radial arterial line was used to monitor blood gases and potential systemic effects of emboli. Duration, size, and severity of emboli as measured by TEE. The operative procedure was divided into 6 distinct stages: preoperative, reduction, guidewire passage, reaming, nail insertion, and postoperative. There was no significant difference in emboli between the RIA and SR groups preoperatively, during fracture reduction, guidewire insertion, or postoperatively. Measured with a standardized scoring system, there was a modest reduction in total emboli score in the RIA group during reaming (SR 5.30 [SD; 1.81] vs. RIA 4.05 [SD; 2.19], P = 0.005) and during nail insertion (SR 5.09 [SD; 1.74] vs. RIA 4.25 [SD; 1.89], P = 0.03). We were unable to correlate this reduction with any improvement in physiologic parameters (mean arterial pressure, end-tidal CO2, O2 saturation, pH, paO2, and paCO2). This study showed a modest reduction of embolic debris during the reaming and nail insertion segments of the operative procedure. We were unable to correlate this with any change in physiologic parameters. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Use of the Reamer/Irrigator/Aspirator Decreases Carotid and Cranial Embolic Events in a Canine Model.

Approximately 2 million patients in the United States annually undergo total joint arthroplasty with reaming and placement of intramedullary nails, resulting in extravasation of bone marrow and fat into the circulatory system and potentially causing fat embolism syndrome. Acute and chronic changes in mental status documented after these procedures may be related to embolic events. The Reamer/Irrigator/Aspirator (RIA) device has been shown to decrease intramedullary pressure during reaming. We hypothesized that the use of the RIA in a canine model would reduce the number of microemboli detected in the carotid artery and brain compared with nailing either with or without reaming. Twenty-four large canines underwent unreamed nailing (UR), sequentially reamed nailing (SR), or RIA-reamed nailing (RIA) of bilateral femora (eight dogs per group). During reaming and nailing, the number and size of microemboli transiting the carotid artery were recorded. After euthanasia, the brain was harvested for immunostaining and measurement of microinfarction volumes. Total embolic load passing through the carotid artery was 0.049 cc (UR), 0.045 cc (SR), and 0.013 cc (RIA). The number and size of microemboli in the UR and SR groups were similar; however, the RIA group had significantly fewer larger-sized (>200-μm) emboli (p = 0.03). Pathologic examination of the brain confirmed particulate emboli, and histologic analyses demonstrated upregulation of stress-related proteins in all groups, with fewer emboli and less evidence of stress for RIA reaming. RIA reaming decreased microemboli compared with traditional reaming and unreamed nailing, suggesting that intramedullary pressure and heat are important variables. The documented embolic events and brain stress may help to explain subtle neurobehavioral symptoms commonly seen in patients after undergoing long-bone reaming procedures. RIA reaming decreased cranial embolic events and may have an ameliorating effect on postoperative neurologic sequelae.

A radiographic and clinical comparison of reamer–irrigator–aspirator versus iliac crest bone graft in ankle arthrodesis

We evaluated radiographic fusion at follow-up and complication rates in patients who had either iliac crest (ICBG) or femoral reamer-irrigator-aspirator (RIA) bone graft for tibiotalar fusion. We retrospectively reviewed charts and radiographs of all patients who had a tibiotalar fusion from August 2007 to February 2011. Records were analysed for patient demographics, complications, and clinical symptoms. Radiographs were reviewed in sequential order by two fellowship-trained foot and ankle surgeons and one orthopaedic surgeon who specialises in foot and ankle surgery to determine radiographic fusion at routine follow-up. Patients were contacted to determine current visual analog scores (VAS) at their graft site. Mean patient age was 49.4 ± 12.1 years in the RIA group and 49.3 ± 15.4 years in the ICBG group (p = .97). Pre-operative characteristics showed no significant differences between groups. The ICBG group had significantly more nonunions than the RIA group (six vs. one, p = 0.04). Two patients in the ICBG had chronic pain at their graft site based on their VAS score; there were none in the RIA group. Radiographic fusion at follow-up was similar between groups, with no significant difference (12.48 ± 3.85 weeks vs.12.21 ± 3.19 weeks, p = .80). There was a significantly higher nonunion rate in the ICBG group, but both groups had a solid radiographic bony fusion at similar follow-up time points. Our results suggest RIA bone graft is a viable alternative to ICBG for tibiotalar fusion.

Comparison of RIA and conventional reamed nailing for treatment of femur shaft fractures

Introduction The standard of care for femoral diaphysis fractures is sequentially reamed, locked, intramedullary nails. However, in the polytraumatized patient perioperative complications such as fat embolism syndrome (FES) and acute respiratory distress (ARDS) are well chronicled. The reamer irrigator aspirator (RIA)has been theorized to minimize such phenomena. Methods A retrospective study comparing conventional reamed nailing for femur fractures versus those treated with the RIA was conducted. From January 2005 to September 2006, 156 patients treated at our institution with an intramedullary nail met inclusion criteria. There were sixty-six patient treated with conventional reaming (group A) and ninety patients treated with the RIA (group B). The main outcome measures included length of hospital stay, rate of ARDS, pneumonia, ventilatory failure, overall pulmonary complications, healing rate and death. Results No significant differences were found between groups with regard to patient demographics, injury severity and the incidence of head/chest trauma. In addition, no differences were found in length of hospital stay, length of ICU stay or mechanical ventilation. Overall pulmonary complications occurred in 11% (group A) and 16% (group B) respectively (p = 0.48). No fatalities were found in group A while there were four in group B, 4% (p = 0.14). No significant differences were found in delayed union versus nonunion rate between groups, while overall healing complications were seen in 7% and 14% of patients (p = 0.35) in groups A and B respectively. Conclusion No statistical significance was reached with regard to pulmonary complications, healing rates or death. However, we were unable to demonstrate favorable physiologic lung parameters with RIA use compared to conventional reaming as has been described in previous animal studies. We found a trend toward more healing complications in the RIA group, but this was not statistically significant. Further study is warranted.

Randomized prospective clinical trial comparing reamer irrigator aspirator (RIA) to standard reaming (SR) in both minimally injured and multiply injured patients with closed femoral shaft fractures treated with reamed intramedullary nailing (IMN)

Purpose To investigate whether inflammatory markers are improved among patients with traumatic femur fractures who undergo RIA reamed intramedullary nailing (IMN) prior to fixation when compared to patients treated with standard reamed (SR) IMN. Methods A prospective, randomized, single-blind trial was conducted on patients who had a closed femoral shaft fracture amenable to reamed IMN. Patients were randomized to undergo IMN with standard reaming or IMN with the RIA in a 1:1 ratio. Patients were stratified by Injury Severity Score (ISS) and by presence or absence of chest injury with AIS > 3. Patients had blood samples and bronchioalveolar lavage samples taken at specified time points pre- and postoperatively. Specimens from SR and RIA cohorts were compared for the presence of IL-2, IL-6, IL-8, TNF, and IL-10 in plasma and IL-1b and IL-8 in bronchioalveolar lavage (BAL) samples to determine the relationship between inflammatory markers and intramedullary reaming. Results Nineteen consecutive patients participated in the study with 9 assigned in the RIA group and 10 in SR group. Significant differences existed for ISS between SR and RIA groups (p=0.04). Bronchial lavage data showed no statistical significant differences when RIA and standard reamers were compared and when ISS >16 and <16 were compared, however there were differences for the bronchial IL-8 change when those with chest injury were compared to those without chest injury. Plasma samples showed a trend towards increased IL-6 and IL-10 levels after reaming consistent with the second hit impact. A trend towards higher levels for IL-6 in the SR group was noted at 24 hours post-operatively whereas the IL-10 levels at the post-reaming time point were higher in the RIA group. Conclusions This prospective study of reamer type indicates that RIA may be protective of systemic inflammation. This is supported by data showing decreased levels of IL-8 in the bronchial washings and increased level of IL-10 in the serum. Reaming and intramedullary fixation may cause an increase in IL-6 levels regardless of reamer type. Further investigations with a larger cohort of patients are desirable.

The systemic inflammatory response following femoral canal reaming using the reamer-irrigator-aspirator (RIA) device

We evaluated the peripheral release of inflammatory mediators after femoral fracture and subsequent intramedullary reaming using the RIA reamers. IL-6 was elevated after trauma, and reaming with RIA induced a measurable second hit response. However, despite a higher ISS, the levels of IL-6 in the RIA group were similar to the levels measured in a group of patients where reaming of the femoral canal was performed using conventional reamers. There was one death related to fat embolism syndrome in the conventional reamers group. However, the overall incidence of complications was low and similar between the 2 groups of studied patients. In polytrauma patients, large scale studies are desirable to evaluate further the immuno-inflammatory response using the RIA reamers prior to the instrumentation of the femoral canal.

Cardiopulmonary Response to Reamed Intramedullary Nailing of the Femur Comparing Traditional Reaming With a One-Step Reamer-Irrigator-Aspirator Reaming System: An Experimental Study in Pigs

Intramedullary reaming and nailing increases intramedullary pressure. This may cause intravasation of bone marrow contents, leading to bone marrow embolization and altered cardiopulmonary function. Possible beneficial effects of attenuation of the intramedullary pressure increase by the use of a reamer-irrigator-aspirator (RIA) system were studied with the hypothesis that the RIA technique would cause lower numbers of pulmonary embolisms (PEs) and lesser cardiopulmonary affection than traditional reaming (TR). Intramedullary reaming and nailing was performed in intact femora of young Norwegian landrace pigs using either a standard intramedullary nailing technique (n = 8) or a RIA technique (n = 7). The hemodynamic and pulmonary effects were investigated during the reaming and nailing procedure and for 2 hours postoperatively. The animals were killed after 72 hours, and the lung/carcass weight ratio and the numbers of PEs were investigated. The pattern of the procedure-related hemodynamic and pulmonary effects did not differ significantly between the RIA and the TR groups. The RIA group had lower numbers (ns) of embolisms per square centimeter lung area than the TR group. After reaming with the TR device, two animals died of PEs, the first postoperative day. The patients with femoral shaft fracture and additional cardiopulmonary injury or preexisting reduced cardiopulmonary function, however, need special attention, and the use of RIA may, in these cases, represent a better operative alternative with a lesser operative burden.

Coagulation, fibrinolysis and cytokine responses to intramedullary nailing of the femur: An experimental study in pigs comparing traditional reaming and reaming with a one-step reamer-irrigator-aspirator system

Introduction Operations in trauma patients represent a second insult and the extent of the surgical procedures influences the magnitude of the inflammatory response. Our hypothesis was that a reamer-irrigator-aspirator (RIA) system would cause a lesser inflammatory response than traditional reaming (TR). Materials and methods Coagulation, fibrinolysis and cytokine responses were studied in Norwegian landrace pigs during and after intramedullary nailing (IMN) with two different reaming systems using ELISA and chromogenic peptide substrate assays. The TR ( n = 8) and the RIA ( n = 7) reaming systems were compared to a control group ( n = 7). The animals were followed for 72 h. Arterial, mixed venous and femoral vein blood were withdrawn simultaneously peroperatively and until 2 h after the nail was inserted for demonstration of local, pulmonary and systemic activation of the cascade systems. At 6 h, 24 h, 48 h and 72 h postoperatively arterial blood samples were withdrawn. Results Significantly procedure-related increased levels were found for thrombin–antithrombin (TAT) and tissue plasminogen activator (t-PA) in the TR group and TAT in the RIA group. The local and the pulmonary activation of coagulation and fibrinolysis were more pronounced in the TR than in the RIA group, the difference reached significance for plasminogen activator inhibitor-1 (PAI-1) (arterial blood). The cytokine response, mainly represented by IL-6 increase, was more pronounced in the TR than the RIA group, and was significant for IL-6 in femoral vein blood. The arterial levels of IL-6 exceeded the mixed venous levels indicating an additional pulmonary activation of IL-6. Two animals in the TR group, who died of pulmonary embolism (PE) prior to planned study end point, had a more pronounced response compared to the rest of the TR group. Conclusion A procedure-related coagulation and fibrinolytic response was demonstrated in both reaming groups, with more pronounced response in the TR than in the RIA group. Elevated levels of cytokines were demonstrated related to reaming and nailing, with significantly higher IL-6 levels in the TR than in the RIA group.

Cortical Heat Generation Using An Irrigating/Aspirating Single-Pass Reaming vs Conventional Stepwise Reaming

To compare the heat generation and pressure generation of a prototype irrigating aspirating intramedullary reaming system to traditional stepwise reaming. This in vitro study used 8 pairs of fresh-frozen human cadaver tibias. Thermocouples were mounted in the mid-diaphysis and distal diaphysis. A pressure transducer was placed distally to assess intramedullary pressure, a load cell measured axial load was applied by the surgeon, and the entire construct was placed in a 37 degrees C saline bath. One specimen from each pair underwent single-pass reaming with the prototype reamer irrigator aspirator (RIA), and the contralateral limb underwent standard stepwise reaming. All variables were recorded. There were no significant differences in pressure applied to the load cells during reaming. The maximum temperatures reached in the distal diaphysis in the RIA group (42.0 +/- 9.1 degrees C) were significantly lower (P = 0.025) than in the standard reaming group (58.7 +/- 15.9 degrees C). The maximum pressure generated in the distal tibia in the RIA group (32.7 +/- 39.4 kPa) was significantly higher (P = 0.019) than in the standard reaming group (17.0 +/- 32.6 kPa). This study demonstrated substantially decreased temperatures with the RIA prototype when compared with standard stepwise reaming. It appears that the continuous flow of room temperature saline irrigant into the system manages to cool the cortical bone, despite the aggressive nature of a single-pass reaming method. However, in this model, contrary to the findings of other studies, the RIA system did generate higher pressures in the distal tibial metaphysis, perhaps as a result of congestion within the outflow of the RIA system. The results of this study confirm that cortical heat generation is not a problem but definitely indicate further development of this prototype aspirator function is warranted, followed by careful in vivo evaluation.

The influence of a one-step reamer-irrigator-aspirator technique on the intramedullary pressure in the pig femur

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.