Learn the Infected femoral nail removal and debridement with Synthes Reamer Irrigator Aspirator (RIA) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Infected femoral nail removal and debridement with Synthes Reamer Irrigator Aspirator (RIA) surgical procedure.
Fracture related infection (FRI) has a spectrum of presentations ranging from early and obvious infection after fracture fixation to delayed presentations with infected non-union of fractures. Its incidence is reported as being between 1-30% of fractures and is more common following open injuries. FRI has various potential aspects to its presentation and management, including bone infection, soft tissue injury, fractures in varying states of healing and metalwork with biofilm. There is currently a lack of high quality evidence to guide practice in this area and there have been a number of recent consensus papers and a BOAST guideline in an attempt to define best practice.
Diagnostic criteria considered to confirm FRI include a sinus, fistula or wound breakdown over bone or implant, purulent discharge or pus found during surgery, phenotypically indistinguishable pathogens from 2 deep samples or histopathological staining for bacteria or fungi. Criteria suggestive of FRI include clinical signs of local inflammation (pain, swelling, redness, temperature), radiological signs (lysis, implant loosening, sequestration, periosteal bone formation), elevated blood markers (WBC, CRP, ESR) or a pathogenic organism grown from a single deep tissue sample.
RIA is made by Synthes, as the name suggests it simultaneously reams, aspirates and irrigates the intramedullary canal as it is passed.
It can be used simply to harvest autologous bone graft for reconstruction cases however it also allows simultaneous reaming of infected material with irrigation as the reamer passes and collection of the reamings to remove and sample infected tissues in infected cases. RIA is not routinely used for primary nailing of fractures as there is an advantage to autografting the fracture site with reamings rather than removing them.
Author:Paul Fenton FRCS (Tr & Orth)
Institution: The Queen Elizabeth Hospital, Birmingham UK.
Surgical Steps – Infected femoral nail removal and debridement with Synthes Reamer Irrigator Aspirator (RIA)
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Surgical Steps
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1. Question
To remove the nail after locking bolt removal a slap-hammer is used, this is part of the Coremus set.
To remove the nail a Coremus IM Nail Extraction set (Aquilant Orthopaedics) is used.
The wounds are then closed in layers using monofilament interrupted sutures.
The reamer is advanced all the way to the distal femur to derbride the entire footprint of the nail.
The slap-hammer is threaded into the extraction bolt.
The extraction bolt position is checked with the image intensifier to confirm that the bolt is not cross-threaded.
At the proximal end the reaming rod is attached to a drive-coupler (1.).
Following nail removal a reaming rod (Synream, 1.)) is placed into the intramedullary canal.
Pellets are then placed in the proximal femur.
After debridement is completed further lavage is performed with saline.
The nail locking bolts can now be removed, first the distal bolts are identified using the image intensifier.
The selected extraction bolt (1.) is loaded onto an extension bar(2.) to make insertion into the nail easier.
To advance the pellets down the femoral shaft a pusher is used.
The previous incision is opened and extended proximally and distally.
The extraction bolt is first threaded into the proximal end of the nail.
The proximal locking bolts are again identified with image intensifier & removed
Samples are taken from the reamings.
Next the irrigation fluid is connected (1.) to the reamer.
The rod position is checked with the image intensifier to ensure it is correctly placed in the intramedullary canal.
Finally the aspirator is attached (1.) to the reamer.
The patient is in a lateral position, bad side up.
The deadspace is filled with Osteoset T (Wright medical) pellets, placed initially in the distal femur.
Filling of the deadspace reduces haematoma formation and the risk of recurrent infection.
The incision is extended through the fascia lata to access the distal locking bolts.
The RIA is then advanced over the reaming rod.
After debridment of the femoral canal the screw holes are debrided.
Before reaming is commenced the suction and irrigation are checked.
To debride the intramedullary canal use the Synthes RIA (Reamer-Irrigator-Aspirator).
