Use of the Reamer–Irrigator–Aspirator May Reduce Tumor Dissemination During Intramedullary Fixation of Malignancies

Abstract

Intramedullary nail fixation is the treatment of choice for impending and pathologic fractures secondary to metastatic cancer; however, this procedure has been shown to cause systemic embolization of intramedullary contents. This article reports the use of the reamer-irrigator-aspirator (RIA) (Synthes, Paoli, Pennsylvania) instead of a standard femoral reamer to decrease tumor intravasation during femoral intramedullary nail fixation for impending or pathologic fractures.Twenty-one consecutive patients indicated for fixation of malignant femoral lesions were treated with intramedullary nail placement. The RIA was used for canal preparation, and solid reamings were collected and submitted for analysis by a single pathologist. The volume of each specimen was recorded, and representative samples were examined histologically to determine their percent tumor content. These data were then used to estimate the volume of tumor retrieved by the RIA in each case. The mean volume of reamings collected by the RIA was 75.0 cc per case (range, 23.4-196.0 cc), and the mean tumor content was 24.8% (range, 1.0%-60.0%). The mean estimated volume of tumor retrieved in each case was 16.7 cc (range, 0.35-36.0 cc). In 2 cases, the tip of the RIA dissociated from the device intraoperatively but was retrieved without adverse consequence to the patient. Use of the RIA in cases of femoral intramedullary nail fixation for pathologic lesions or fractures effectively retrieves variable amounts of intramedullary contents, including tumor. By preventing the systemic dissemination of malignant cells, this technique may reduce the risk of distant metastases.

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

“…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 [7][8][9] . 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 [8] . Cipriano et al [7] , reported 2 cases and Eisenstein et al [9] , 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.…”

“…Like any other procedure, it is not devoid of potential complications: These include procedure-related complications including iatrogenic femur fractures [5] , post-operative pain at the entry site [6] , and increased blood loss due to continuous suction [3] . Hardware-related complications have been reported but they are rare and have included reamer head dissociation [ 7 , 8 ] as well as breakage of the drive shaft tip [9] in the canal but these can be easily addressed using the ball-tip guidewire for a quick and easy reamer head extraction [7][8][9] .…”

Treatment of femoral metastases

“…Cipriano et al 15 investigated the use of the RIA in the treatment of 21 patients with malignant femoral lesions and found they were able remove on average 16.7 cc (0.35--36 cc) of tumor in the reamings. The reamer-irrigator-aspirator (RIA) (Synthes, Paoli, Pennsylvania) has been proposed to decrease this risk.…”

Complications associated using the reamer–irrigator –aspirator (RIA) system: a systematic review and meta-analysis

“…Indeed, preclinical large animal studies showed that application of the RIA system was associated with a reduced amount of FE [ 19 , 20 ] and lower systemic effects compared to conventional reaming [ 21 , 22 ]. Based on these findings, the RIA system has been applied to reduce intravasation of intramedullary content, such as malignancies [ 23 ], infections [ 24 ], and cement removal [ 25 ]. However, systematic reporting of the associated complications is essential; yet, surprisingly, no systematic review of the complications associated with the use of the RIA system has been conducted.…”