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

  • George D. Chloros
    Affiliations
    Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom
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  • Vasileios P. Giannoudis
    Affiliations
    Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom
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  • Nikolaos K. Kanakaris
    Affiliations
    Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom
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  • Peter V. Giannoudis
    Correspondence
    Corresponding author at: Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom.
    Affiliations
    Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom

    NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
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Open AccessPublished:January 25, 2022DOI:https://doi.org/10.1016/j.injury.2022.01.039

      Highlights

      • Breakage of the RIA-2 system reamer head with persistence of metal debris in the femoral canal has never been reported.
      • This is a frustrating and challenging situation in which the surgeon may be seriously left without an option but to abandon them inside the canal.
      • A technical trick using a combination of instruments is provided as a bailout from this distressing situation.

      Abstract

      The Reamer-Irrigator-Aspirator (RIA-2) system has been established as a safe and reliable device to harvest large amounts of autograft. Nevertheless, hardware complications may occur. Breakage of the reamer head from the drive shaft with intramedullary retention of small metal debris has never been dealt with. The authors provide a technical trick as a bailout in this difficult situation.

      Keywords

      Introduction

      The Reamer-Irrigator-Aspirator system (DePuy Synthes®, West Chester, PA) or “RIA”, is an autograft collecting system capable of bone graft volumes output ranging from 30 to 90 cm3 [
      • Madison R.D.
      • Nowotarski P.J.
      The Reamer-Irrigator-Aspirator in nonunion surgery.
      ,
      • Yee M.A.
      • Hundal R.S.
      • Perdue A.M.
      • Hake M.E.
      Autologous bone graft harvest using the Reamer-Irrigator-Aspirator.
      ]. It is generally considered a safe, reliable and efficient device of autograft harvest [
      • Madison R.D.
      • Nowotarski P.J.
      The Reamer-Irrigator-Aspirator in nonunion surgery.
      ,
      • Haubruck P.
      • Ober J.
      • Heller R.
      • Miska M.
      • Schmidmaier G.
      • Tanner M.C.
      Complications and risk management in the use of the reaming-irrigator-aspirator (RIA) system: RIA is a safe and reliable method in harvesting autologous bone graft.
      ], equivalent to iliac crest bone grafting as far as union rates, infection or revision procedures, but superior to it regarding donor site pain, surgical pain and volume of bone graft harvested [
      • Dawson J.
      • Kiner D.
      • Gardner W.
      • Swafford R.
      • Nowotarski P.J
      The Reamer-Irrigator-Aspirator as a device for harvesting bone graft compared with iliac crest bone graft: union rates and complications.
      ].
      Like any other procedure, it is not devoid of potential complications: These include procedure-related complications including iatrogenic femur fractures [
      • Han F.
      • Peter L.
      • Lau E.T.
      • Thambiah J.
      • Murphy D.
      • Kagda F.H.
      Reamer Irrigator Aspirator bone graft harvesting: complications and outcomes in an Asian population.
      ], post-operative pain at the entry site [
      • Calori G.M.
      • Colombo M.
      • Mazza E.L.
      • Mazzola S.
      • Malagoli E.
      • Mineo G.V.
      Incidence of donor site morbidity following harvesting from iliac crest or RIA graft.
      ], and increased blood loss due to continuous suction [
      • Haubruck P.
      • Ober J.
      • Heller R.
      • Miska M.
      • Schmidmaier G.
      • Tanner M.C.
      Complications and risk management in the use of the reaming-irrigator-aspirator (RIA) system: RIA is a safe and reliable method in harvesting autologous bone graft.
      ]. Hardware-related complications have been reported but they are rare and have included reamer head dissociation [
      • Cipriano C.A.
      • Arvanitis L.D.
      • Virkus W.W.
      Use of the Reamer-Irrigator-Aspirator may reduce tumor dissemination during intramedullary fixation of malignancies.
      ,
      • Kanakaris N.K.
      • Morell D.
      • Gudipati S.
      • Britten S.
      • Giannoudis P.V.
      Reaming Irrigator Aspirator system: early experience of its multipurpose use.
      ] as well as breakage of the drive shaft tip [
      • Eisenstein E.D.
      • Waterman B.R.
      • Kanlic E.M.
      • Abdelgawad A.A.
      A new technique for obtaining bone graft in cases of distal femur nonunion: passing a Reamer/Irrigator/Aspirator retrograde through the nonunion site.
      ] in the canal but these can be easily addressed using the ball-tip guidewire for a quick and easy reamer head extraction [
      • Cipriano C.A.
      • Arvanitis L.D.
      • Virkus W.W.
      Use of the Reamer-Irrigator-Aspirator may reduce tumor dissemination during intramedullary fixation of malignancies.
      ,
      • Kanakaris N.K.
      • Morell D.
      • Gudipati S.
      • Britten S.
      • Giannoudis P.V.
      Reaming Irrigator Aspirator system: early experience of its multipurpose use.
      ,
      • Eisenstein E.D.
      • Waterman B.R.
      • Kanlic E.M.
      • Abdelgawad A.A.
      A new technique for obtaining bone graft in cases of distal femur nonunion: passing a Reamer/Irrigator/Aspirator retrograde through the nonunion site.
      ].
      The authors provide a technical trick of how to successfully remove persistent small metal debris in the intramedullary canal following breakage of the reamer head. This previously unreported complication is challenging and a bailout is possible.

      Surgical technique

      Illustrative case

      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 [
      • Masquelet A.C.
      • Begue T.
      The concept of induced membrane for reconstruction of long bone defects.
      ]. 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 [
      • Giannoudis P.V.
      • Einhorn T.A.
      • Marsh D.
      Fracture healing: 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 [
      • Yee M.A.
      • Hundal R.S.
      • Perdue A.M.
      • Hake M.E.
      Autologous bone graft harvest using the Reamer-Irrigator-Aspirator.
      ]. 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. 2AC). 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. 3AC. Finally, a new RIA-2 set was used, and the procedure was completed successfully.
      Fig 1
      Fig. 1AP fluoroscopic view of the broken reamer head, extracted with the use of the ball-tip guide-wire. Note the four small residual metal debris in the femoral canal.
      Fig 2
      Fig. 2A–C: (A) Curettes and graspers of different sizes used. Fluoroscopic image of a curette (B) and a grasper(C) which allowed pulling of the metal debris to the proximal femoral region.
      Fig 3
      Fig. 3A–C: Using the Stryker nail extraction hook (A and B), successful extraction (C) of the metal debris (D).

      Discussion

      The RIA-2 is made of a disposable reamer head, drive shaft, tubes for irrigation/aspiration, a graft harvesting filter and the RIA containment tubing. The reamer head is designed to firmly engage to the disposable tube assembly and drive shaft. Dissociation and/or breakage of the reamer head or driver shaft inside the canal while reaming has been rarely reported and in all cases the reamer head that had disengaged was successfully retrieved using the ball tip guidewire [
      • Cipriano C.A.
      • Arvanitis L.D.
      • Virkus W.W.
      Use of the Reamer-Irrigator-Aspirator may reduce tumor dissemination during intramedullary fixation of malignancies.
      ,
      • Kanakaris N.K.
      • Morell D.
      • Gudipati S.
      • Britten S.
      • Giannoudis P.V.
      Reaming Irrigator Aspirator system: early experience of its multipurpose use.
      ,
      • Eisenstein E.D.
      • Waterman B.R.
      • Kanlic E.M.
      • Abdelgawad A.A.
      A new technique for obtaining bone graft in cases of distal femur nonunion: passing a Reamer/Irrigator/Aspirator retrograde through the nonunion site.
      ]. There are no reports of metal debris from the reamer head persisting in the intramedullary canal apart from this current situation presented herein therefore no alternative methods of extraction have been reported.
      Kanakaris et al., reported one case of reamer head dissociation due to poor connection of the reamer head to the reamer shaft [
      • Kanakaris N.K.
      • Morell D.
      • Gudipati S.
      • Britten S.
      • Giannoudis P.V.
      Reaming Irrigator Aspirator system: early experience of its multipurpose use.
      ]. Cipriano et al. [
      • Cipriano C.A.
      • Arvanitis L.D.
      • Virkus W.W.
      Use of the Reamer-Irrigator-Aspirator may reduce tumor dissemination during intramedullary fixation of malignancies.
      ], reported 2 cases and Eisenstein et al. [
      • Eisenstein E.D.
      • Waterman B.R.
      • Kanlic E.M.
      • Abdelgawad A.A.
      A new technique for obtaining bone graft in cases of distal femur nonunion: passing a Reamer/Irrigator/Aspirator retrograde through the nonunion site.
      ], reported 5 cases of intraoperative breakage of the drive shaft causing head-shaft dissociation during reaming. In all reports, the head was easily removed by pulling it up using the ball tip guidewire, as in our patient. However, no metal debris persisted in the canal and therefore, there was no need for further action and none of the authors were faced with a similar problem. Like in the case presented herein, the likely explanation is missing as this may be attributed to either improper assembly, surgeon error with forcibly pushing the RIA into the canal, or RIA malfunction.
      In contrast, in the case described herein, although retrieval of the bulk of the head was also quick and easy, the four metal pieces that serve to attach/lock the head into the drive shaft remained into the canal causing extended intra-operative time and the need to improvise extraction using a variety of instruments described.

      Conclusion

      Head-shaft dissociation with breakage of the reamer head and residual retained metal debris is a unique complication during reaming with the RIA-2 system and results in a frustrating situation for the surgeon who may be tempted to abandon extraction. The key message is that a combination of different instruments may be used to successfully extract those metal debris and avoid leaving them inside the canal. Their removal facilitated re-using the RIA-2 for obtaining the necessary bone grafting for successfully treating the traumatic right femoral bone loss.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Acknowledgment

      The authors declare that no funding has been received in relation to this article.

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