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. 2016 Apr 20;98(8):658-64.
doi: 10.2106/JBJS.14.01176.

Use of the Reamer/Irrigator/Aspirator Decreases Carotid and Cranial Embolic Events in a Canine Model

Anna N Miller  1 , Dwight Deal  2 , James Green  3 , Timothy Houle  2 , William Brown  2 , Clara Thore  2 , David Stump  2 , Lawrence X Webb  4
Affiliations

Use of the Reamer/Irrigator/Aspirator Decreases Carotid and Cranial Embolic Events in a Canine Model

Anna N Miller et al. J Bone Joint Surg Am. .

Abstract

Background: Approximately 2 million patients in the United States annually undergo total joint arthroplasty with reaming and placement of intramedullary nails, resulting in extravasation of bone marrow and fat into the circulatory system and potentially causing fat embolism syndrome. Acute and chronic changes in mental status documented after these procedures may be related to embolic events. The Reamer/Irrigator/Aspirator (RIA) device has been shown to decrease intramedullary pressure during reaming. We hypothesized that the use of the RIA in a canine model would reduce the number of microemboli detected in the carotid artery and brain compared with nailing either with or without reaming.

Methods: Twenty-four large canines underwent unreamed nailing (UR), sequentially reamed nailing (SR), or RIA-reamed nailing (RIA) of bilateral femora (eight dogs per group). During reaming and nailing, the number and size of microemboli transiting the carotid artery were recorded. After euthanasia, the brain was harvested for immunostaining and measurement of microinfarction volumes.

Results: Total embolic load passing through the carotid artery was 0.049 cc (UR), 0.045 cc (SR), and 0.013 cc (RIA). The number and size of microemboli in the UR and SR groups were similar; however, the RIA group had significantly fewer larger-sized (>200-μm) emboli (p = 0.03). Pathologic examination of the brain confirmed particulate emboli, and histologic analyses demonstrated upregulation of stress-related proteins in all groups, with fewer emboli and less evidence of stress for RIA reaming.

Conclusions: RIA reaming decreased microemboli compared with traditional reaming and unreamed nailing, suggesting that intramedullary pressure and heat are important variables. The documented embolic events and brain stress may help to explain subtle neurobehavioral symptoms commonly seen in patients after undergoing long-bone reaming procedures.

Clinical relevance: RIA reaming decreased cranial embolic events and may have an ameliorating effect on postoperative neurologic sequelae.

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Figures

Fig. 1
Fig. 1
Percent change in cerebrospinal fluid (CSF) fluorescein sodium salt (SF) after reaming (R) for the Reamer/Irrigator/Aspirator (RIA), unreamed (UR), and sequentially reamed (SR) groups.
Fig. 2
Fig. 2
Total embolic load, defined as the sum of all emboli from the beginning to the completion of the procedure. Differences in embolic load were not significant due to wide variance and the small sample size of each group. However, there appeared to be fewer outliers for Reamer/Irrigator/Aspirator (RIA) reaming. UR = unreamed, and SR = sequentially reamed.
Fig. 3
Fig. 3
Size and number of microemboli; note the logarithm scale on this figure. The Reamer/Irrigator/Aspirator (RIA) group had significantly fewer larger-sized (>200-μm) emboli. UR = unreamed, and SR = sequentially reamed.
Fig. 4
Fig. 4
An embolus (arrow) within an alkaline phosphatase-stained cerebral capillary (×20).
Fig. 5
Fig. 5
Heat-shock-protein (HSP)-labeled cells per brain volume. Mean differences were significant. RIA = Reamer/Irrigator/Aspirator, UR = unreamed, and SR = sequentially reamed.
Fig. 6
Fig. 6
Hypoxia-inducible-factor (HIF)-labeled cells. Mean differences were significant. RIA = Reamer/Irrigator/Aspirator, UR = unreamed, and SR = sequentially reamed.
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References

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