Injury, Int. J.

Care Injured 41 (2010) S2, S43S47

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Injury
journal homepage: www.elsevier.com/locate/injury

Treatment of long bone intramedullary infection using the RIA for removal of infected tissue: Indications, method and clinical results
Charalampos G. Zalavrasa, *, Michael Sirkinb, *
a Department b Department

of Orthopaedics, Keck School of Medicine, University of Southern California, LAC + USC Medical Center, Los Angeles, CA, USA of Orthopaedics, UMDNJ-New Jersey Medical School, North Jersey Orthopaedic Institute, Newark, NJ, USA

article info
Keywords: Intramedullary Infection Osteomyelitis Debridement Nail Reamer Reaming Irrigation Antibiotics

abstract
Treatment of intramedullary infections of long bones is based upon the principles of surgical debridement, irrigation, fracture site stabilization, soft tissue coverage, and antibiotic administration. Reaming of the medullary canal is an essential component of surgical debridement because it removes intramedullary debris and infected bone surrounding the removed intramedullary device and within the intramedullary canal. The ReamerIrrigatorAspirator (RIA) has distinct features that appear to be benecial for management of intramedullary infections. It allows reaming under simultaneous irrigation and aspiration, which minimizes the residual amount of infected uid and tissue in the medullary canal and the propagation of infected material. The disposable reamer head is sharp, which combined with the continuous irrigation may attenuate the increased temperature associated with reaming and its potential adverse effects on adjacent endosteal bone. The disadvantage of the RIA is increased cost because of use of disposable parts. Potential complications can be avoided by detailed preoperative planning and careful surgical technique. The RIA should be used with caution in patients with narrow medullary canals and in infections involving the metaphysis or a limited part of the medullary canal. Reaming of the canal is performed with one pass of the RIA under careful uoroscopic control. Limited information is available in the literature on the results of the RIA for management of intramedullary infections of long bones; however preliminary results are promising. The RIA device appears to be an effective and safe tool for debridement of the medullary canal and management of intramedullary infections of the long bones. Further research is needed to clarify the exact contribution of the RIA in the management of these infections. 2010 Elsevier Ltd. All rights reserved.

Introduction Intramedullary infections of long bones usually occur following internal xation of fractures frequently after treatment with intramedullary devices. Intramedullary spread also occurs from local spread in focal osteomyelitis or after open fracture treatment. Treatment of these infections is challenging and based upon the principles of surgical debridement and irrigation, fracture site stabilization, soft tissue coverage, and antibiotic administration.2,12,21 Surgical debridement is the most important step and inadequate debridement is the most common cause of persistence or
* Corresponding authors. Charalampos G. Zalavras M.D. Professor, Department of Orthopaedics, Keck School of Medicine, University of Southern California, LAC + USC Medical Center, 1200 N. State St., GNH 3900, Los Angeles, CA 90033, USA E-mail address: zalavras@usc.edu (C.G. Zalavras). Michael Sirkin M.D. Vice Chairman, Department of Orthopaedics Associate Professor UMDNJ-New Jersey Medical School North Jersey Orthopaedic Institute 140 Bergen St. Suite D 1610, Newark, NJ 07103 E-mail address: sirkinms@umdnj.edu (M. Sirkin).
0020-1383/ $ see front matter 2010 Elsevier Ltd. All rights reserved.

recurrence of infection.23 The presence of foreign bodies, avascular or dead bone and necrotic soft tissue is associated with development of biolm, which protects bacteria from host defense mechanisms and antibiotics and precludes eradication of infection.25 Therefore, surgical debridement should include removal of the intramedullary nail when present, debridement of the fracture site and surrounding soft tissues, and reaming and irrigation of the medullary canal.20,21,26 Reaming of the medullary canal is an essential component of surgical debridement because it removes intramedullary debris and infected bone surrounding the removed intramedullary device and within the intramedullary canal.7,10,16,17,19 Reaming is associated with concerns regarding bone overheating, especially with dull reamers, and propagation of infected material along the distal end of the medullary canal, into surrounding bone and into the circulation.5 The ReamerIrrigatorAspirator (RIA) [Synthes, Paoli, PA] is a relatively new device that allows reaming of the medullary canal under simultaneous irrigation and aspiration in order to reduce embolization of fat and inammatory mediators during reaming and the development of the fat embolism syndrome.4,9,18 Pape and coauthors reported that use of the RIA device in a sheep

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intramedullary nailing model in the presence of pulmonary injury attenuates the systemic effects of intramedullary reaming.18 A recent study by Husebye and coworkers showed in a pig model that the RIA device resulted in signicant reduction in interleukin 6 levels compared to conventional reamers.9 The RIA has found application for fracture xation in polytrauma patients but also for harvesting of non-structural bone graft.3,6,13,22 An additional application of the device that has not been well described is debridement of intramedullary infections of long bones. Therefore, in this review we will present the surgical technique and will discuss the indications, contraindications, advantages, disadvantages, and clinical results of the device when used for management of long bone intramedullary infections. Indications and contraindications The RIA device is indicated for debridement and irrigation of the medullary canal for management of intramedullary infections of long bones, usually following intramedullary nailing. When an infection develops in the presence of an intramedullary nail there is potential extension of the infection along the entire device and medullary canal. Following removal of the nail, the whole length of the canal needs to be debrided so that pus, infected debris, and infected endosteal bone be removed. Reaming of the medullary canal offers a useful technique for debridement of these extensive intramedullary infections and the RIA can be used instead of conventional reamers to take advantage of the additional useful features (irrigation and aspiration) of the new device. Another indication is when treating local osteomyelitis and there has been spread to the intramedullary canal. This is best diagnosed by the presence of intramedullary edema as seen on an MRI scan (Fig. 1).

it may result to excessive bone removal, weakening of the residual cortex, and iatrogenic fracture.11 Method of application Preoperative planning As in all cases of osteomyelitis, detailed preoperative planning is necessary before embarking on the treatment of a patient with an intramedullary infection. Evaluation of several variables having to do with the microorganism, the patient, the extremity, the soft tissue envelope, the bone, and the existing implants is necessary in order to develop a comprehensive management plan.21 We will not describe in detail all these variables of preoperative planning but we will briey outline them. Important factors to assess include: (a) the type and antibiotic resistance of the involved microorganism(s), (b) the patients medical status, comorbidities, functional needs and expectations, (c) the neurovascular and functional status of the extremity, (d) the quality and integrity of the soft tissue envelope and the extent of infection into the soft tissues, i.e. soft-tissue abscesses and sinus tracts, (e) the presence of any deformity, (f) the status of bone healing, the presence of sequestra, the extent of medullary canal involvement, the medullary canal diameter, (g) the type, size, and integrity of any existing implants, (h) the need for bone stabilization with new ones, and nally (i) the need for local antibiotic delivery. Evaluation of the involved bone and existing implants is particularly important prior to medullary canal reaming with the RIA device. Imaging studies should be reviewed to assess the status of bone healing and therefore need for stabilization of the fracture following removal of an existing implant. Preoperative identication of sequestra will assist the surgeon in their removal and should alert him/her for the possibility of a bone defect and further reconstructive procedures. If an intramedullary device is not in place, the extent of medullary canal involvement should be assessed by MRI to determine the need for reaming of the canal, and the narrowest diameter of the canal should be measured to avoid overreaming. The type of an existing intramedullary nail should be determined from radiographs and from information in the medical chart to facilitate extraction by using specic extraction instruments. The integrity of the implants should be assessed so that the surgeon is prepared to remove broken ones. Finally, determination of the diameter of the nail allows preoperative evaluation of the required diameter of the disposable reamer head. Our preference is to use a reamer head of diameter no more than 2 to 3 mm greater than the diameter of the existing nail in order to avoid excessive reaming. The thickness of the existing cortex should also be assessed. This is particularly important in the tibia because of the eccentric starting point and the sharp turn of the reamer at the proximal diaphysis. Surgical technique After removal of an existing intramedullary nail, the diameter of the implant is conrmed and a sterile reamer head of the appropriate diameter is opened. A 2.5 mm reaming rod is inserted into the medullary canal, advanced distally to the physeal scar, and its central position in the canal is conrmed with uoroscopy in orthogonal views. The RIA device consists of three disposable components (a reamer head, a tube assembly, a driveshaft seal) and a reusable driveshaft. The driveshaft is connected to the tube assembly and then to the reamer head. At times it is necessary to connect the reamer head to the tube assembly rst and then insert the drive shaft correctly aligned into the assembled tube and reamer head. The tube assembly has one irrigation and one aspiration port, which are connected to irrigation uid and to operating room suction, respectively. If the organism has not been identied, a canister,

Fig. 1. Left: MRI-T1 image showing intramedullary involvement with surrounding abscess. Right: MRI-T2 image above showing intramedullary edema and infection.

However, the RIA is contraindicated or should be used with caution in the following situations. First, reaming of the medullary canal is not recommended for infections that are localized to a limited part of the medullary canal without proximal or distal extension, such as infections following plate xation or external xation of diaphyseal fractures. In these cases the involvement of the medullary canal is usually limited to the area of inserted screws or pins. Reaming may disseminate infected material into previously normal canal and will also disrupt the endosteal circulation. Second, if the cancellous bone of the metaphyseal area is involved reaming will not be effective in debriding it due to the increased diameter of the canal. In this case, an elongated oval cortical window will provide improved access to the medullary canal and is preferable.24 If the infection extends into the diaphysis, the bone window can be combined with medullary canal reaming. Third, the RIA is contraindicated in patients with narrow medullary canals. Currently, the smallest diameter of the reamer is 12 mm, so if it is used in a patient with a much narrower canal

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Fig. 2. Collection canister used to obtain specimen to be sent for microbiology (Biomet, Warsaw, IN).

which is typically used to collect bone graft, can be used and the content sent for culture and sensitivity (Fig. 2). The RIA is connected to power as a drill and not as a reamer, because it is designed to operate at high speed and low torque.6 Reaming of the canal is performed with one pass of the RIA under careful uoroscopic control and with simultaneous irrigation and aspiration. A back and forth motion is recommended to allow the utes and tube assembly to clear the bone and infected material. If not done, the tube assembly can become clogged and not function as it is intended to. After reaming, the RIA is used for further debridement and irrigation of the medullary canal. The device is disconnected from power and is manually advanced into the canal and used as a curette for further scraping of the bone under continuous irrigation and aspiration. Further irrigation of the medullary canal is performed using a total of 10 L of uid. Canal irrigation may also be performed prior to the application of the RIA device (Fig. 3). At the completion of debridement local antibiotic delivery in the medullary canal, in the form of antibiotic impregnated beads or spacers, can be used to help control the infection. Antibiotic beads can be made from polymethylmethacrylate (PMMA) or a bioabsorbable material (Fig. 4). Antibiotic PMMA beads require early removal to avoid incarceration into the medullary canal and may be used only when an early reoperation is planned. If there is some instability or a nonunion is present an intramedullary spacer can be used, which consists of a metal rod coated with antibiotic impregnated PMMA (Figs. 5 and 6) [Both of these techniques are not FDA-approved in the United States].

Fig. 4. (A) Antibiotic impregnated PMMA beads on wire suture; (B) antibiotic impregnated Osteoset (Wright Medical, Arlington, TN) beads on suture; (C) Osteoset beads inserted into intramedullary canal after fracture healing and hardware removal.

Fig. 5. (A) Antibiotic rod made on a beaded tip guide wire; (B) same rod inserted into a tibia, external xation added for improved stability.

Fig. 6. Antibiotic rod made on a threaded Ilizarov rod (Smith & Nephew, Memphis, TN) and inserted into a tibia with adequate stability obtained by rod alone. Fig. 3. Intramedullary irrigation of a tibia prior to using RIA, note distal vent hole with suction connected to prevent embolization of infection and marrow.

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Clinical results Limited information is available in the literature on the results of the RIA for management of intramedullary infections of long bones.1,3,26 The rst and only clinical series, to our knowledge, has been reported by Zalavras and colleagues in 2007.26 In this retrospective study, the authors described use of the RIA for management of 11 patients with intramedullary infections in the presence of an intramedullary nail. Infection involved the tibia in 8 patients, the femur in 3 patients, and developed at a median time of 10 months after treatment of the initial injury, which was an open fracture in the majority of cases. The most common microorganism was Staphylococcus aureus, which was present in 9 of 11 patients and was oxacillin-resistant in 3 of these. All procedures were performed by a single surgeon with a consistent protocol that included removal of existing intramedullary nails, fracture site debridement, and medullary canal reaming with the RIA device. Patients were treated with culture-specic antibiotics for 6 weeks. At a mean followup time of 13 months (range, 6 to 23 months) there was no recurrence of infection. There were no intraoperative complications. Postoperative complications included partial loss of a ap in one patient, external xator pin tract infections in one patient, and refracture of the tibia in one patient. The last patient who had osteomyelitis of the tibia after a segmental open fracture sustained a refracture at the distal fracture site 4 months after debridement after he was hit by an automobile; the fracture united uneventfully following cast immobilization. Bellapianta and co-authors presented a case report of a patient with a 20-year history of chronic osteomyelitis of the femur following an open fracture that was internally xed and subsequently infected.1 Upon presentation to the authors the patient had a history of intermittent drainage and imaging studies demonstrated a healed fracture, no implants in place, and evidence of intramedullary infection and sequestra. The partially obliterated medullary canal was opened and reamed using the RIA. At one year postoperatively there was no evidence of infection recurrence. Finally, Finkemeier and colleagues reported the use of RIA for various indications on 23 patients and in one of these patients the device was used for treatment of osteomyelitis of the tibia but no specic details were provided.3 Discussion The RIA device has distinct features that appear to be benecial for the management of intramedullary infections. In contrast to conventional reamers, the RIA device allows reaming under simultaneous irrigation and aspiration, which minimizes the residual amount of infected uid and tissue in the medullary canal and the propagation of infected material along the distal end of the medullary canal, into the surrounding bone and into the circulation. This leads, in our opinion, to more effective debridement and irrigation that may facilitate control of infection. In addition, the reamer head is disposable and always sharp in contrast to conventional ones, which are used multiple times and become blunt over time leading to generation of increased temperature during reaming.14,15 Therefore, the sharp reamer head combined with the continuous irrigation may attenuate the increased temperature associated with reaming,8 and its potential adverse effects on the adjacent endosteal bone. This may result in increased preservation of endosteal bone viability that would be benecial in cases of intramedullary infections in order to resist reinfection by any residual microorganisms. Therefore, the RIA device has the potential to minimize problems associated with conventional reamers and to improve the efcacy of the reaming procedure. The current limited literature appears

promising but in the only clinical series there was no control group and no comparison of the RIA device to conventional reamers was performed. Therefore, it remains unclear if the advantageous features of the RIA device translate to improved outcome of long bone intramedullary infections. A prospective, randomized multicenter study would be the ideal investigation to clarify this issue. The main disadvantage of the RIA device is the increased cost because of the use of disposable parts. Complications directly associated with use of the RIA for debridement of intramedullary infections have not been reported in the small number of patients reported in the literature. However, the use of the RIA for other applications has resulted in complications, such as iatrogenic fractures.11 These complications can be avoided by paying close attention to the indications, contraindications, planning, and execution of the procedure. In conclusion, the RIA device appears to be an effective, safe, and useful tool for debridement of the medullary canal and management of intramedullary infections of the long bones. Further research is needed to clarify the exact contribution of the RIA in the management of these challenging infections. Competing interests Charalampos Zalavras: No nancial relationships that could inappropriately inuence this work. Michael Sirkin: No nancial relationships that could inappropriately inuence this work. Dr. Sirkin is an AO instructor. Funding There were no sources of funding associated with the manuscript. References
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