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Laubach M, Bessot A, Saifzadeh S, Savi FM, Hildebrand F, Bock N, Hutmacher DW, McGovern J. In vivo study to assess fat embolism resulting from the Reamer-Irrigator-Aspirator 2 system compared to a novel aspirator-based concept for intramedullary bone graft harvesting. Arch Orthop Trauma Surg 2024; 144:1535-1546. [PMID: 38367064 PMCID: PMC10965743 DOI: 10.1007/s00402-024-05220-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 02/08/2024] [Indexed: 02/19/2024]
Abstract
INTRODUCTION Fat embolism (FE) following intramedullary (IM) reaming can cause severe pulmonary complications and sudden death. Recently, a new harvesting concept was introduced in which a novel aspirator is used first for bone marrow (BM) aspiration and then for subsequent aspiration of morselized endosteal bone during sequential reaming (A + R + A). In contrast to the established Reamer-Irrigator-Aspirator (RIA) 2 system, the new A + R + A concept allows for the evacuation of fatty BM prior to reaming. In this study, we hypothesized that the risk of FE, associated coagulopathic reactions and pulmonary FE would be comparable between the RIA 2 system and the A + R + A concept. MATERIALS AND METHODS Intramedullary bone graft was harvested from intact femora of 16 Merino sheep (age: 1-2 years) with either the RIA 2 system (n = 8) or the A + R + A concept (n = 8). Fat intravasation was monitored with the Gurd test, coagulopathic response with D-dimer blood level concentration and pulmonary FE with histological evaluation of the lungs. RESULTS The total number and average size of intravasated fat particles was similar between groups (p = 0.13 and p = 0.98, respectively). D-dimer concentration did not significantly increase within 4 h after completion of surgery (RIA 2: p = 0.82; A + R + A: p = 0.23), with an interaction effect similar between groups (p = 0.65). The average lung area covered with fat globules was similar between groups (p = 0.17). CONCLUSIONS The use of the RIA 2 system and the novel A + R + A harvesting concept which consists of BM evacuation followed by sequential IM reaming and aspiration of endosteal bone, resulted in only minor fat intravasation, coagulopathic reactions and pulmonary FE, with no significant differences between the groups. Our results, therefore, suggest that both the RIA 2 system and the new A + R + A concept are comparable technologies in terms of FE-related complications.
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Affiliation(s)
- Markus Laubach
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, 4000, Australia.
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, 4059, Australia.
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Agathe Bessot
- Max Planck Queensland Centre for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD, 4000, Australia
- Centre for Biomedical Technologies, School of Biomedical Sciences, Faculty of Health, and Translational Research Institute (TRI), Queensland University of Technology (QUT), Brisbane, QLD, 4102, Australia
- Translational Research Institute (TRI), 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Siamak Saifzadeh
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, 4000, Australia
- Medical Engineering Research Facility, Queensland University of Technology, Chermside, QLD, 4032, Australia
| | - Flavia Medeiros Savi
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, 4000, Australia
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, 4059, Australia
- Max Planck Queensland Centre for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD, 4000, Australia
| | - Frank Hildebrand
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nathalie Bock
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, 4000, Australia
- Max Planck Queensland Centre for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD, 4000, Australia
- Centre for Biomedical Technologies, School of Biomedical Sciences, Faculty of Health, and Translational Research Institute (TRI), Queensland University of Technology (QUT), Brisbane, QLD, 4102, Australia
- Translational Research Institute (TRI), 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Dietmar W Hutmacher
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, 4000, Australia
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, 4059, Australia
- Max Planck Queensland Centre for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD, 4000, Australia
- ARC Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4000, Australia
| | - Jacqui McGovern
- Max Planck Queensland Centre for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD, 4000, Australia
- Centre for Biomedical Technologies, School of Biomedical Sciences, Faculty of Health, and Translational Research Institute (TRI), Queensland University of Technology (QUT), Brisbane, QLD, 4102, Australia
- ARC Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4000, Australia
- Translational Research Institute (TRI), 37 Kent Street, Woolloongabba, QLD, 4102, Australia
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Kristiansen S, Jarmund AH, Hilmo J, Mollnes TE, Leth-Olsen M, Nyrnes SA, Nilsen BA, Grønli RH, Faldaas BO, Storm B, Espenes A, Nielsen EW. Femoral Nailing in a Porcine Model Causes Bone Marrow Emboli in the Lungs and Systemic Emboli in the Heart and Brain. JB JS Open Access 2024; 9:e23.00128. [PMID: 38419616 PMCID: PMC10898662 DOI: 10.2106/jbjs.oa.23.00128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Background Shaft fractures of the femur are commonly treated with intramedullary nailing, which can release bone marrow emboli into the bloodstream. Emboli can travel to the lungs, impairing gas exchange and causing inflammation. Occasionally, emboli traverse from the pulmonary to the systemic circulation, hindering perfusion and resulting in injuries such as heart and brain infarctions, known as fat embolism syndrome. We studied the extent of systemic bone marrow embolization in a pig model. Methods Twelve anesthetized pigs underwent bilateral intramedullary nailing of the femur, while 3 animals served as sham controls. Monitoring included transesophageal echocardiography (TEE), pulse oximetry, electrocardiography, arterial blood pressure measurement, and blood gas and troponin-I analysis. After surgery, animals were monitored for 240 minutes before euthanasia. Post mortem, the heart, lungs, and brain were biopsied. Results Bone marrow emboli were found in the heart and lungs of all 12 of the pigs that underwent intramedullary nailing and in the brains of 11 of them. No emboli were found in the sham group. The pigs subjected to intramedullary nailing exhibited significant hypoxia (PaO2/FiO2 ratio, 410 mm Hg [95% confidence interval (CI), 310 to 510) compared with the sham group (594 mm Hg [95% CI, 528 to 660]). The nailing group exhibited ST-segment alterations consistent with myocardial ischemia and a significant increase in the troponin-I level compared with the sham group (1,580 ng/L [95% CI, 0 to 3,456] versus 241 ng/L [95% CI, 0 to 625] at the 240-minute time point; p = 0.005). TEE detected emboli in the right ventricular outflow tract, but not systemically, in the nailing group. Conclusions Bilateral intramedullary nailing caused bone marrow emboli in the lungs and systemic emboli in the heart and brain in this pig model. The observed clinical manifestations were consistent with coronary and pulmonary emboli. TEE detected pulmonary but not systemic embolization. Clinical Relevance Femoral intramedullary nailing in humans is likely to result in embolization as described in our pig model. Focused monitoring is necessary for detection of fat embolism syndrome. Absence of visual emboli in the left ventricle on TEE does not exclude the occurrence of systemic bone marrow emboli.
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Affiliation(s)
- Steinar Kristiansen
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Anders Hagen Jarmund
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jonas Hilmo
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Tom Eirik Mollnes
- Research Laboratory, Nordland Hospital, Bodø, Norway
- Department of Immunology, Oslo University Hospital, University of Oslo, Norway
| | - Martin Leth-Olsen
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Children's Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Siri Ann Nyrnes
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Children's Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Bent Aksel Nilsen
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | | | - Bjørn Ove Faldaas
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Benjamin Storm
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Arild Espenes
- Department of Basic Sciences and Aquatic Medicine, Norwegian School of Veterinary Science, Oslo, Norway
| | - Erik Waage Nielsen
- Department of Surgery, Nordland Hospital, Bodø, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
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Mills H, Acquah R, Tang N, Cheung L, Klenk S, Glassen R, Pirson M, Albert A, Hoang DT, Van TN. Emergency Medicine with Advanced Surgery Protocols: A Review. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2022; 2022:3513250. [PMID: 36200087 PMCID: PMC9529385 DOI: 10.1155/2022/3513250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/17/2022]
Abstract
One of the most burning issues in health system is the concern of handling patients that requires emergency surgery. Emergency general surgery is done on both traumatic and nontraumatic acute disorders. Severe traumatic injury and bleeding is one of the causing agents for high mortality rate globally. Another group of patients that are in need of emergency surgery are those with heart failure, and in this particular paper, we analyzed emergency medicine with advanced surgery protocols focusing on gastric cancer, cardiac surgery, and bleeding as well as coagulopathy following traumatic injury.
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Affiliation(s)
- Hilla Mills
- Clinical Center of Vojvodina, Novi Sad, Serbia
- Clinical Analysis Lab, Center of Bio-Medicine, Hanoi, Vietnam
| | - Ronald Acquah
- Clinical Center of Vojvodina, Novi Sad, Serbia
- Clinical Analysis Lab, Center of Bio-Medicine, Hanoi, Vietnam
| | - Nova Tang
- RD Lab, The Hospital Institute for Herbal Research, 50200 Toluca, MEX, Mexico
| | - Luke Cheung
- RD Lab, The Hospital Institute for Herbal Research, 50200 Toluca, MEX, Mexico
| | - Susanne Klenk
- Research Institution of Clinical Biomedicine, Hospital University Medical Centre, 89000 Ulm, Germany
| | - Ronald Glassen
- Research Institution of Clinical Biomedicine, Hospital University Medical Centre, 89000 Ulm, Germany
| | - Magali Pirson
- Industrial Research Group, International College of Science and Technology, Route de Lennik 800, CP 590, 1070 Brussels, Belgium
| | - Alain Albert
- Industrial Research Group, International College of Science and Technology, Route de Lennik 800, CP 590, 1070 Brussels, Belgium
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Abstract
The management of multiply injured or severely injured patients is a complex and dynamic process. Timely and safe fracture fixation is a critical component of the multidisciplinary care that these patients require. Effective management of these patients, and their orthopaedic injuries, requires a strong understanding of the pathophysiology of the response to trauma and indicators of patient status, as well as an appreciation for the dynamic nature of these parameters. Substantial progress in both clinical and basic science research in this area has advanced our understanding of these concepts and our approach to management of the polytraumatized patient. This article summarizes a symposium on this topic that was presented by an international panel of experts at the 2020 Virtual Annual Meeting of the Orthopaedic Trauma Association.
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Rosser K, Wilton S, Farrington WJ. Fat Embolism Syndrome: The Ambiguity of Diagnosis in the Postarthroplasty Patient: A Case Report. JBJS Case Connect 2021; 10:e1900594. [PMID: 32649144 DOI: 10.2106/jbjs.cc.19.00594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CASE We present the case of an otherwise healthy, 74-year-old woman, who underwent bilateral hip arthroplasty and subsequently presented with decreased level of consciousness, mimicking a severe postoperative delirium. After several days and investigations, the diagnosis of fat embolism syndrome (FES) was reached, and appropriate management was given. CONCLUSION Orthopedic surgeons and their teams should consider FES as a differential diagnosis of prolonged post-operative delirium. With supportive management these patients can make a full recovery without lasting neurological symptoms. Our patient has shown no subsequent sequelae after 10-month follow-up.
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Affiliation(s)
- Kenrick Rosser
- 1Department of Orthopaedics, North Shore Hospital, Waitemata DHB, Auckland, New Zealand
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Abstract
Fat embolism (FE) occurs frequently after trauma and during orthopaedic procedures involving manipulation of intramedullary contents. Classically characterized as a triad of pulmonary distress, neurologic symptoms, and petechial rash, the clinical entity of FE syndrome is much less common. Both mechanical and biochemical pathophysiologic theories have been proposed with contributions of vascular obstruction and the inflammatory response to embolized fat and trauma. Recent studies have described the relationship of embolized marrow fat with deep venous thrombosis and postsurgical cognitive decline, but without clear treatment strategies. Because treatment is primarily supportive, our focus must be on prevention. In trauma, early fracture stabilization decreases the rate of FE syndrome; however, questions remain regarding the effect of reaming and management of bilateral femur fractures. In arthroplasty, computer navigation and alternative cementation techniques decrease fat embolization, although the clinical implications of these techniques are currently unclear, illustrating the need for ongoing education and research with an aim toward prevention.
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Voskuil RT, Viscomi B, Holt GE, Bruce J. Reamer-Irrigator-Aspirator Multiuse Application in the Treatment of Chronic Osteomyelitis. J Orthop Case Rep 2019; 9:47-50. [PMID: 32548003 PMCID: PMC7276632 DOI: 10.13107/jocr.2250-0685.1528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction The treatment of chronic intramedullary infection of the long bones relies on microbe-specific antibiotics in conjunction with surgical removal of infected necrotic material. We discuss the use of reamer–irrigator–aspirator(RIA) for debridement of the intramedullary canal instead of conventional reaming techniques. This is the first case report to explore the use of RIA for osteomyelitis. Case Report We discuss the use of the RIA in treatment of a 26-year-old female presenting with chronic osteomyelitis of the left distal femoral shaft. She had normalization of infection laboratories at 6 weeks and complete resolution of symptoms at 3 months and was released at 6 months. Conclusion Recent exploration of the RIA system’s (Synthes®, Inc. West Chester, Philadelphia) multipurpose applications has indicated use in long bone debridement. While further exploration and high-quality studies are needed to make robust claims of efficacy, we believe that the use of RIA in the context of chronic osteomyelitis is a superior alternative to conventional reaming techniques.
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Affiliation(s)
- Ryan T Voskuil
- Department of Orthopaedic Surgery, University of Tennessee College of Medicine, Tennessee 975 E. Third Street, Hospital Box 260,Chattanooga, TN 37403, United States
| | - Brian Viscomi
- Department of Orthopaedic Surgery, East Tennessee State University Quillen School of Medicine, 1276 Gilbreath Dr, Johnson City, TN 37614, United States
| | - Ginger E Holt
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, 1211 Medical Center Drive, Nashville, TN 37232, United States
| | - Jeremy Bruce
- Department of Orthopaedic Surgery, University of Tennessee College of Medicine, Tennessee 975 E. Third Street, Hospital Box 260,Chattanooga, TN 37403, United States
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Healing, nonunion, and re-operation after internal fixation of diaphyseal and distal femoral fractures: a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2018. [PMID: 29516238 DOI: 10.1007/s00264-018-3864-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Nonunion is a highly morbid complication that exacerbates the pain, disability and financial burden of distal and diaphyseal femur fractures. This study examined the modern rates of healing, nonunion, and other complications requiring reoperation of different fixation methods for distal and diaphyseal femur fractures. METHODS A systematic review and meta-analysis of all records from PubMed, Embase and the Cochrane Review system was performed. Included studies had >20 acute, non-pathologic distal or diaphyseal femur fractures treated with primary internal fixation. Excluded were studies on abnormal patient/fracture populations, external fixation, or cement/bone graft use. RESULTS Thirty-eight studies with 2,829 femoral shaft fractures and 11 studies with 505 distal femur fractures were included. Distal fractures had a lower healing rate (86.6% vs. 93.7%) and a higher re-operation rate (13.4% vs 6.1%) than shaft fractures (p < 0.00001), primarily due to higher rates of mechanical failure (p < 0.00001). Nonunion was the most frequent complication, occurring in 4.7% of distal fractures and 2.8% of shaft fractures. There was no difference between plate and nail fixation of distal fractures in healing, nonunion, or other causes of re-operation. Shaft fractures developed nonunion in 6.6% of unreamed nails and 2.1% of reamed nails (p = 0.002). Nonunion occurred in 2.3% of antegrade nailed fractures and 1.5% of retrograde nailed fractures (p = 0.66). CONCLUSIONS Approximately one out of every eight distal fractures and one of every 16 shaft fractures requires re-operation. The most common cause of fixation failure is nonunion. Further research is needed to improve outcomes, particularly in distal femur fractures.
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Guerado E, Caso E. Challenges of bone tissue engineering in orthopaedic patients. World J Orthop 2017; 8:87-98. [PMID: 28251059 PMCID: PMC5314152 DOI: 10.5312/wjo.v8.i2.87] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/23/2016] [Accepted: 11/22/2016] [Indexed: 02/06/2023] Open
Abstract
Bone defects may impede normal biomechanics and the structural stability of bone as an organ. In many cases, the correction of bone defects requires extensive surgical intervention involving the use of bone-grafting techniques and other procedures in which healing is slow, there is a high risk of infection and considerable pain is provoked - with no guarantee of complete correction of the defect. Therefore, the search for surgical alternatives continues to present a major challenge in orthopaedic traumatology. The reamer-irrigator-aspirator (RIA) system, which was devised to avoid the problems that can arise with autograft harvesting from the iliac crest, consists of collecting the product of the femoral canal after reaming. The RIA technique improves osteogenic differentiation of mesenchymal stem cells, compared to bone marrow aspiration or cancellous bone harvesting from the iliac crest using a spoon. Another approach, the Masquelet technique, consists of reconstructing a long bone defect by means of an induced membrane grown onto an acrylic cement rod inserted to fill the defect; in a second surgical step, once the membrane is constituted, the cement rod is removed and cancellous autograft is used to fill the defect. Both in RIA and in the Masquelet technique, osteosynthesis is usually needed. Bone transportation by compression-distraction lengthening principles is commonly implemented for the treatment of large bone loss. However, complications are frequently encountered with these techniques. Among new techniques that have been proposed to address the problem of large bone loss, the application of stem cells in conjunction with tissue engineering techniques is very promising, as is the creation of personalised medicine (or precision medicine), in which molecular profiling technologies are used to tailor the therapeutic strategy, to ensure the right method is applied for the right person at the right time, after determining the predisposition to disease among the general population. All of the above techniques for addressing bone defects are discussed in this paper.
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