Pathogenesis and clinical relevance of bone marrow embolism in medullary nailing — demonstrated by intraoperative echocardiography

Wenda, K.; Runkel, M.; Degreif, J.; Ritter, G.

doi:10.1016/0020-1383(93)90011-t

Cited by 171 publications

(66 citation statements)

References 14 publications

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“…Several of the studies [12][13][14][15][16] measured IM pressures as a measure of FE, and whilst elevated IM pressures have been shown to be associated with FE [30], this is an indirect measurement and some studies have suggested this per se may not be directly related [31]. In addition, the threshold at which FE in humans occurs is unknown, although we note the work from Wenda et al suggesting a 200-mmHg threshold in the sheep model [32]. It is concerning that one paper recorded elevated distal pressures compared to conventional reaming but this is out of step with other studies [12].…”

Section: Prevention Of Fat Embolism and Thermal Necrosismentioning

confidence: 81%

Reamer-irrigator-aspirator indications and clinical results: a systematic review

Cox

Jones

McGonagle

et al. 2011

International Orthopaedics (SICOT)

126

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Background The 'reamer-irrigator-aspirator' (RIA) is an innovation developed to reduce fat embolism (FE) and thermal necrosis (TN) that can occur during reaming/ nailing of long-bone fractures. Since its inception its indications have expanded to include the treatment of long-bone osteomyelitis and as a harvester of bone graft/ mesenchymal stem cells (MSCs). Methods This study involved a systematic review, via Pubmed® and Google Scholar®, of English language sources (nine non-clinical studies, seven clinical studies and seven case reports) using the keywords: 'reamer', 'irrigator', 'aspirator' (1st May 2010). Sources were reviewed with reference to the RIAs efficacy in (1) preventing FE/TN, (2) treating long-bone osteomyelitis, (3) harvesting bone graft/MSCs, and (4) operating safely. Experimental data supports the use of the RIA in preventing FE and TN, however, there is a paucity of clinical data. Conclusions The RIA is a reliable method in achieving high volumes of bone graft/MSCs, and high union rates are reported when using RIA bone-fragments to treat nonunions. Evidence suggests possible effectiveness in treating long-bone osteomyelitis. The RIA appears relatively safe, with a low rate of morbidity provided a meticulous technique is used. When complications occur they respond well to conventional techniques. The RIA demands further investigation especially with respect to the optimal application of MSCs for bone repair strategies.

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Section: Prevention Of Fat Embolism and Thermal Necrosismentioning

confidence: 81%

Reamer-irrigator-aspirator indications and clinical results: a systematic review

Cox

Jones

McGonagle

et al. 2011

International Orthopaedics (SICOT)

126

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“…The reaming procedure has been shown to cause an increase in intramedullary pressure, embolisation of bonemarrow contents into the lung and release of inflammatory mediators. 28 The potential of triglycerides to damage alveolar architecture is well described. 6 Hyperstimulation of the inflammatory system, either by single or multiple 'hits', is considered by many to be the key element in the pathogenesis of ARDS and MOF.…”

Section: Discussionmentioning

confidence: 99%

Stimulation of the inflammatory system by reamed and unreamed nailing of femoral fractures

Giannoudis

Smith

Bellamy

et al. 1999

The Journal of Bone and Joint Surgery. British volume

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It has been suggested that reamed intramedullary nailing of the femur should be avoided in some patients with multiple injuries. We have studied prospectively the effect of femoral reaming on the inflammatory process as implicated in the pathogenesis of acute respiratory distress syndrome (ARDS) and multiple-organ failure (MOF). We studied changes in the levels of serum interleukin-6 (IL-6) (proinflammatory cytokine), neutrophil CD11b (C3) receptor expression (activated neutrophil adhesion molecule), serum soluble intracellular adhesion molecule (s-ICAM-1), serum soluble E-selectin (the soluble products of endothelial adhesion molecules) and plasma elastase (neutrophil protease) in a series of patients with femoral fractures treated by nailing. We have also compared reamed nailing with unreamed nailing.We found that the levels of serum IL-6 and elastase rose significantly during the nailing procedure indicating a measurable 'second hit'. There was no clear response in leukocyte activation and no difference in the release of endothelial adhesion molecule markers. There was no significant difference between groups treated by reamed and unreamed nailing. Although clinically unremarkable, the one patient who died from ARDS was shown to be hyperstimulated after injury and again after nailing, suggesting the importance of an excessive inflammatory reaction in the pathogenesis of these serious problems.Our findings have shown that there is a second hit associated with femoral nailing and suggest that the degree of the inflammatory reaction may be important in the pathogenesis of ARDS and MOF.

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“…We chose to use 200 mm Hg as the threshold for fat embolism based on the work of Wenda et al [21] in a sheep model. Pape et al [17] attempted to validate the sheep model and concluded the effect of intramedullary instrumentation in sheep is less pronounced than in humans because the ratios of the femur and vertebral column differ.…”

Section: Discussionmentioning

confidence: 99%

“…The number of fat particles observed in the lungs postoperatively correlates with increased femoral intramedullary pressure when a TKA is performed using conventional instrumentation (eg, drill, intramedullary alignment guide, and so on) [10,16]. Although the exact femoral intramedullary pressure threshold that leads to fat embolism has not been studied in humans [13], a sheep model suggests emboli (bone marrow surrounded by a thrombotic aggregate) appear at intramedullary pressures greater than 200 mm Hg [21].…”

Section: Introductionmentioning

confidence: 99%

The Reamer/Irrigator/Aspirator Reduces Femoral Canal Pressure in Simulated TKA

Gorp

Falk

Kmiec

et al. 2009

Clinical Orthopaedics &Amp; Related Research

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Inserting the femoral intramedullary alignment rod during total knee arthroplasty (TKA) can generate high intramedullary pressure, which increases the risk of intraoperative complications caused by fat embolism. Despite modifications to the surgical procedure, the best method to prevent this increase in pressure remains unknown. The reamer/irrigator/aspirator is a surgical instrument designed for use during femoral canal entry to increase the canal size and remove intramedullary fat and may prevent this pressure increase. We posed two hypotheses: (1) using the reamer/ irrigator/aspirator system will result in lower maximum femoral intramedullary pressure than using only conventional instrumentation during the initial steps of a TKA; and (2) using the reamer/irrigator/aspirator system in the initial steps of TKA will result in a mean maximum intramedullary pressure less than 200 mm Hg. We simulated a TKA on 14 cadaveric femurs to compare the femoral intramedullary pressure using both methods. Considerable decreases in femoral intramedullary pressure of 86% proximally and 87% distally were obtained by using the reamer/irrigator/aspirator system. The mean maximum pressure using the reamer/irrigator/aspirator system was less than 200 mm Hg. Additional clinical studies are needed to confirm any reduction in complications using the reamer/irrigator/aspirator system.

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Pathogenesis and clinical relevance of bone marrow embolism in medullary nailing — demonstrated by intraoperative echocardiography

Cited by 171 publications

References 14 publications

Reamer-irrigator-aspirator indications and clinical results: a systematic review

Reamer-irrigator-aspirator indications and clinical results: a systematic review

Stimulation of the inflammatory system by reamed and unreamed nailing of femoral fractures

The Reamer/Irrigator/Aspirator Reduces Femoral Canal Pressure in Simulated TKA

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