A technical note: How to extract broken Reamer-Irrigator-Aspirator (RIA) metal intramedullary debris

An otherwise healthy 33-year-old-female restrained driver presented to the Emergency Department following a high-speed motor vehicle head on collision. Her GCS was 15 and was neurovascularly intact in all four extremities. Her injuries included a grade IIIB open right femoral shaft fracture with bone loss, as well as a right fourth metatarsal shaft fracture, left patella fracture, left talus fracture and left fifth metatarsal fracture. There were no other injuries. Following ATLS assessment and appropriate resuscitation measures, she underwent prompt irrigation, debridement and retrograde nail fixation of her right femur. A cement spacer was applied at the area of bone loss loaded with vancomycin for control of infection, management of dead space and for creation of the induced membrane (1st stage Masquelet technique) for bone regeneration at a later stage []. Her other aforementioned injuries were also addressed operatively, including debridement and fixation with patellar tendon re-attachment of her left patella, percutaneous pinning of her right fourth metatarsal shaft fracture, open reduction and internal fixation of her left talus and left fifth metatarsal fracture. There were no complications.

After 12 weeks, the patient was readmitted to undergo an elective second stage Masquelet procedure for her right femoral bone defect to be managed with RIA-2 autograft harvest from her contralateral femur in combination with bone marrow aspirate concentrate (BMAC) and BMP-2 according to the diamond concept []. The patient was positioned supine on the OSI table. After obtaining BMAC from her left iliac crest, the RIA-2 device was used in order to harvest autograft from her left femur using a previously described standard technique []. Briefly, a stab incision was made 5 cm above the greater trochanter and entry point to femoral canal was made. Subsequently, an entry guidewire was advanced to the level of the knee, and following measurement of the canal diameter, a 12.5 mm diameter RIA-2 reamer head was selected. The apparatus was correctly assembled, and the device was inserted into the canal. The reamer advanced slowly, and care was taken to ensure frequent back and forth movements to avoid clogging. Fluoroscopy was used to make sure eccentric reaming was avoided. Continuous reaming was carried out but at about the junction of the proximal and middle thirds of the femur the surgeon experienced difficulty advancing the RIA and therefore reaming was stopped. A fluoroscopy image was taken revealing that there was dissociation with fragmentation of part of the reamer head, with residual metal debris in the canal (Fig. 1). Initially, the bulk of the reamer head was removed by retracting the ball-tip guide wire, however the four small metal pieces coming from the head still persisted in the canal. Next, a combination of curettes and graspers of different sizes were used to advance them in a retrograde fashion, however, this was only partially successful (Fig. 2A–C). As a last resort, the idea of extracting the bits using a nail extraction hook from the stryker implant extraction kit (Stryker® Inc, Kalamazoo, MI) was put into action. Using the nail extraction hook under fluoroscopic control all the broken metal parts were successfully extracted as shown in Fig. 3A–C. Finally, a new RIA-2 set was used, and the procedure was completed successfully.