Donor site morbidity with reamer-irrigator-aspirator (RIA) use for autogenous bone graft harvesting in a single centre 204 case series

doi:10.1016/j.injury.2013.06.008

Injury

Volume 44, Issue 10, October 2013, Pages 1263-1269

https://doi.org/10.1016/j.injury.2013.06.008 Get rights and content

Abstract

Donor site morbidity and complication rate using the reamer-irrigator-aspirator (RIA) system for intramedullary, non-structural autogenous bone graft harvesting were investigated in a retrospective chart and radiographic review at a University affiliated Level-1 Trauma Centre. 204 RIA procedures in 184 patients were performed between 1/1/2007 and 12/31/2010. RIA-indication was bone graft harvesting in 201 (98.5%), and intramedullary irrigation and debridement in 3 (1.5%) cases. Donor sites were: femur – antegrade 175, retrograde 4, tibia – antegrade 7, retrograde 18. Sixteen patients had undergone two RIA procedures, two had undergone three procedures, all using different donor sites. In 4 cases, same bone harvesting was done twice. Mean volume of bone graft harvested was 47 ± 22 ml (20–85 ml). The complication rate was 1.96% (N = 4). Operative revisions included 2 retrograde femoral nails for supracondylar femur fractures 6 and 41 days postoperatively (antegrade femoral RIA), 1 trochanteric entry femoral nail (subtrochanteric fracture) 17 days postoperatively (retrograde femoral RIA) and 1 prophylactic stabilization with a trochanteric entry femoral nail for intraoperative posterior femoral cortex penetration without fracture. In our centre, the RIA technique has a low donor site morbidity and has been successfully implemented for harvesting large volumes of nonstructural autogenous bone graft.

Introduction

Intramedullary nailing, first introduced by Gerhard Küntscher in the 1940s was succeeded by the reaming technique to improve the strength of fixation in the mid 1950s and concerns regarding complications were soon recognized. Marrow embolization, increased intramedullary pressure and thermal necrosis were first addressed using a negative pressure suction-irrigation device developed by Dankwardt-Lillieström in the late 1960s [1]. Further technical improvement and development allowed access the intramedullary canal with significantly less pressure and heat. The reamer-irrigator-aspirator system (RIA, Synthes Inc., West Chester, PA) in its current design, clinically introduced in 2003, made the reaming contents available as a source of nonstructural bone graft. Multiple quantitative and qualitative analyses of harvested intramedullary graft have demonstrated high concentrations of various growth factors including FGF-α, PDGF, IGF-I, TGF-β1 and BMP-2. Osteogenic differentiation of bone marrow progenitor cells (mesenchymal stem cells, endothelial- and CD34+ progenitor cells) have been described as well, suggesting a tremendous therapeutic potential while maintaining biomechanical properties of the donor bone [2], [3], [4], [5], [6]. Autologous bone graft currently remains the only clinically available source with osteogenic, osteoinductive and osteoconductive properties. Intramedullary bone graft harvesting has become more prevalent with only limited published data on patient selection, risk assessment and complications [7], [8], [9], [10], [11], [12], [13], [14]. The purpose of this study was to describe the donor site morbidity and operative complication rate in a large, single centre case series.

Section snippets

Patients and methods

Following the approval of the University Institutional Review Board, the medical records, operative/clinic notes and imaging studies of all patients who had undergone a RIA procedure at our University affiliated Level-1 Trauma Centre between 1/1/2007 and 12/31/2010 were reviewed. This time frame comprises the first, and all consecutive RIA patients without any exclusion. Variables of interest included the date and type of complication, any operative revision for infection, fracture, impending

Results

During the 48 month review period, 1200 bone graft harvesting procedures were performed, including 612 (51%) iliac crest and 204 (17%) RIA procedures in 184 patients. Four experienced, fellowship-trained full time orthopaedic faculty members were involved in all procedures. Intraoperative fluoroscopy was used to assess the starting point and to approximate the reamer head size after templating and device pretesting. It was systematically and routinely performed to monitor guide-wire positioning

Discussion

The reamer-irrigator-aspirator system was initially developed to address the negative effects of intramedullary canal instrumentation by negative pressure reaming with a high speed, low torque device in combination with continuous irrigation and aspiration [15], [16], [17], [18], [19]. The technical ability to continuously aspirate and collect large amounts of intramedullary tissue with tremendous therapeutic potential, propagated the reamer-irrigator-aspirator technique. Although the iliac

Conflict of interest

None of the authors has any financial or personal relationships with people or organizations that could inappropriately influence or bias their work.

None of the authors has any employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding related to this work.

Disclaimer

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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