infected nails

7/31/2019 Infected Nails

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Injury, Int. J. Care Injured 41 (2010) S2, S43S47

Contents lists available at ScienceDirect

Injury

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / i n j u r y

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

a r t i c l e i n f o

Keywords:

IntramedullaryInfection

Osteomyelitis

Debridement

Nail

Reamer

Reaming

Irrigation

Antibiotics

a b s t r a c t

Treatment of intramedullary infections of long bones is based upon the principles of

surgical debridement, irrigation, fracture site stabilization, soft tissue coverage, and antibioticadministration. 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 beneficial for

management of intramedullary infections. It allows reaming under simultaneous irrigation and

aspiration, which minimizes the residual amount of infected fluid 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 fluoroscopic 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 fixation 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 andbased 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: [email protected] (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: [email protected] (M. Sirkin).

recurrence of infection.23 The presence of foreign bodies, avascular

or dead bone and necrotic soft tissue is associated withdevelopment of biofilm, which protects bacteria from hostdefense mechanisms and antibiotics and precludes eradication

of infection.25 Therefore, surgical debridement should includeremoval of the intramedullary nail when present, debridement of

the fracture site and surrounding soft tissues, and reaming andirrigation of the medullary canal.20,21,26

Reaming of the medullary canal is an essential component ofsurgical debridement because it removes intramedullary debris and

infected bone surrounding the removed intramedullary device andwithin the intramedullary canal.7,10,16,17,19 Reaming is associated withconcerns regarding bone overheating, especially with dull reamers,

and propagation of infected material along the distal end of themedullary canal, into surrounding bone and into the circulation.5

The ReamerIrrigatorAspirator (RIA) [Synthes, Paoli, PA] is arelatively new device that allows reaming of the medullary canal

under simultaneous irrigation and aspiration in order to reduceembolization of fat and inflammatory 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

0020-1383/ $ see front matter 2010 Elsevier Ltd. All rights reserved.


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S44 C.G. Zalavras, M. Sirkin/ Injury, Int. J. Care Injured 41 (2010) S43S47

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 significant reduction in interleukin 6

levels compared to conventional reamers.9

The RIA has found application for fracture fixation 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 longbones. 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, infecteddebris, 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).

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 distalextension, such as infections following plate fixation or external

fixation 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

it may result to excessive bone removal, weakening of the residualcortex, 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 havingto do with the microorganism, the patient, the extremity, the soft

tissue envelope, the bone, and the existing implants is necessary inorder to develop a comprehensive management plan.21 We will notdescribe in detail all these variables of preoperative planning but we

will briefly outline them. Important factors to assess include: (a) thetype and antibiotic resistance of the involved microorganism(s),(b) the patients medical status, comorbidities, functional needsand expectations, (c) the neurovascular and functional status of the

extremity, (d) the quality and integrity of the soft tissue envelopeand the extent of infection into the soft tissues, i.e. soft-tissueabscesses and sinus tracts, (e) the presence of any deformity, (f) the

status of bone healing, the presence of sequestra, the extent ofmedullary canal involvement, the medullary canal diameter, (g) thetype, size, and integrity of any existing implants, (h) the need for

bone stabilization with new ones, and finally (i) the need for localantibiotic delivery.

Evaluation of the involved bone and existing implants isparticularly important prior to medullary canal reaming with the

RIA device. Imaging studies should be reviewed to assess the statusof bone healing and therefore need for stabilization of the fracturefollowing removal of an existing implant. Preoperative identification

of sequestra will assist the surgeon in their removal and shouldalert him/her for the possibility of a bone defect and furtherreconstructive procedures. If an intramedullary device is not inplace, the extent of medullary canal involvement should be assessed

by MRI to determine the need for reaming of the canal, and thenarrowest diameter of the canal should be measured to avoid over-reaming.

The type of an existing intramedullary nail should be determinedfrom radiographs and from information in the medical chart tofacilitate extraction by using specific extraction instruments. The

integrity of the implants should be assessed so that the surgeonis prepared to remove broken ones. Finally, determination of thediameter of the nail allows preoperative evaluation of the requireddiameter of the disposable reamer head. Our preference is to use a

reamer head of diameter no more than 2 to 3 mm greater than thediameter 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 startingpoint and the sharp turn of the reamer at the proximal diaphysis.

Surgical technique

After removal of an existing intramedullary nail, the diameter of theimplant is confirmed and a sterile reamer head of the appropriatediameter is opened. A 2.5 mm reaming rod is inserted into the

medullary canal, advanced distally to the physeal scar, and itscentral position in the canal is confirmed with fluoroscopy inorthogonal views.

The RIA device consists of three disposable components (a reamerhead, 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 reamerhead to the tube assembly first and then insert the drive shaftcorrectly aligned into the assembled tube and reamer head. Thetube assembly has one irrigation and one aspiration port, which

are connected to irrigation fluid and to operating room suction,

respectively. If the organism has not been identified, a canister,


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C.G. Zalavras, M. Sirkin/ Injury, Int. J. Care Injured 41 (2010) S43S47 S45

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 fluoroscopic control and with simultaneous irrigation and

aspiration. A back and forth motion is recommended to allow the

flutes 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 10L of fluid. 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 maybe 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. 3. Intramedullary irrigation of a tibia prior to using RIA, note distal vent hole

with suction connected to prevent embolization of infection and marrow.

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 fixation 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.


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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 first 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-specific antibiotics for 6 weeks. At a mean follow-

up 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 flap in one

patient, external fixator pin tract infections in one patient, and

refracture of the tibia in one patient. The last patient who hadosteomyelitis 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 fixed 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 forvarious indications on 23 patients and in one of these patients the

device was used for treatment of osteomyelitis of the tibia but no

specific details were provided.3

Discussion

The RIA device has distinct features that appear to be beneficial

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 fluid 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 andirrigation 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

beneficial 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 efficacy

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 multi-

center 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 intramedullaryinfections 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 financial relationships that could

inappropriately influence this work. Michael Sirkin: No financial

relationships that could inappropriately influence this work. Dr.

Sirkin is an AO instructor.

Funding

There were no sources of funding associated with the manuscript.

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