The goal of this surgical technique video (see Video, Supplemental Digital Content 1, http://links.lww.com/JOT/A395) is to demonstrate autologous bone graft harvest using the reamer–irrigator–aspirator (RIA). Initially developed to reduce intramedullary pressures during long bone intramedullary nail placement, the RIA system can be used to harvest large volume autologous bone graft from the intramedullary canal of a long bone.1 Preoperative planning and appropriate operative technique is paramount to successfully and safely harvest bone graft through the RIA system.
The video presents a case involving a previously healthy 34-year-old man who sustained a Gustilo–Anderson type 3-A open right tibia fracture with a diaphyseal segmental bone loss of 6.5 cm. Despite urgent debridement, this injury was complicated by tibial osteomyelitis, which required placement of an antibiotic intramedullary nail, multiple debridements, and antibiotic spacer applications in preparation for reconstruction using the induced membrane technique.2 Once the infection was successfully cleared, the patient was ready for second-stage bone grafting. The surgeon chose to use RIA-derived autograft harvested from the femur, as it has been shown to provide a large volume of bone rich in growth factors and mesenchymal stem cells. Furthermore, there are several reports documenting decreased postoperative pain at the graft donor site when using RIA-derived bone graft as compared to iliac crest bone graft.3,4
Preoperatively, it is important to measure the intramedullary canal diameter of the femur on available imaging. In general, a reamer head 1–1.5 mm larger than the measured diameter is used to obtain bone graft. Because the smallest available reamer head is 12 mm, a preoperative intramedullary canal diameter smaller than 10.5 mm would be a contraindication to using the RIA system to harvest bone graft.
The patient is positioned supine on a radiolucent operating table with fluoroscopy coming in from the contralateral side. The reamer head is chosen using a radiographic gauge placed over the thigh at the isthmus, ensuring 1–1.5 mm of cortical overlap with the chosen size.
Similar to a trochanteric entry femoral nail, a starting point at the tip of the greater trochanter is established. It is important to avoid a lateral starting point, as the goal is to minimize the entry angle into the femoral canal to prevent eccentric cortical reaming and iatrogenic fracture. After entry reaming, the guide wire is advanced under fluoroscopic guidance, making sure that it remains in the center of the canal. To reduce the risk of intraarticular penetration, the guide wire should not be advanced distal to the distal femoral physeal scar. Alternatively, a piriformis or retrograde starting point can be used as long as the surgeon ensures that the guide wire remains in the center of the canal as discussed.5
After correct assembly of the RIA apparatus with the chosen reamer head, inflow fluid tubing, and aspiration tubing attached to the filtered graft canister, the RIA is advanced over the guide wire. Correct reamer advancement technique is key to obtain adequate graft and avoid complications. The reamer should be advanced slowly, a few centimeters at a time, with frequent withdrawals several centimeters to allow for emulsification of the intramedullary canal material by the irrigation fluid and to avoid clogging of the aspiration holes. It is important to take frequent fluoroscopic shots during reaming to monitor for eccentric cortical reaming.5 The surgeon should continuously ream while advancing, as the initial torque and friction of the reamer head restarting within a tight canal can result in iatrogenic fracture or fragmentation of the reamer head from the reamer drive shaft.
The graft canister should be monitored for volume of harvested graft throughout reaming. The harvested graft is a dense slurry that can be mixed with cancellous allograft or demineralized bone matrix in a 3:1 ratio to increase the volume of graft to fill a defect.6
After reaming, it is important to check for cortical perforation or iatrogenic fracture using full length anteroposterior and lateral fluoroscopic images. Postoperatively, the patient is allowed to bear weight as tolerated on the graft donor extremity, provided that there are no other injuries requiring restriction.
Reported outcomes when using RIA-derived bone graft to fill segmental bone defects using the induced membrane technique demonstrate successful union in 82.6%–90% of patients.7–9
1. Nauth A, Watson JT, Giannoudis P. Bone graft substitution and augmentation. J Orthop Trauma. 2015;29:S34–S38.
2. Masquelet AC, Begue T. The concept of induced membrane
for reconstruction of long bone defects. Orthop Clin North Am. 2010;41:27–37.
3. Calori GM, Colombo M, Mazza EL, et al. Incidence of donor site morbidity following harvesting from iliac crest or RIA graft. Injury. 2014;45(suppl 6):S116–S120.
4. Dawson J, Kiner D, Gardner W II, et al. The reamer-irrigator-aspirator as a device for harvesting bone graft compared with iliac crest bone graft: union rates and complications. J Orthop Trauma. 2014;28:584–590.
5. Quintero AJ, Tarkin IS, Pape HC. Technical tricks when using the reamer irrigator aspirator technique for autologous bone graft harvesting. J Orthop Trauma. 2015;24:42–45.
6. Mauffrey C, Hake ME, Chadayammuri V, et al. Reconstruction of long bone infections using the induced membrane
technique: tips and tricks. J Orthop Trauma. 2016;30:e188–e193.
7. McCall TA, Brokaw DS, Jelen BA, et al. Treatment of large segmental bone defects with reamer-irrigator-aspirator bone graft: technique and case series. Orthop Clin North Am. 2010;41:63–73.
8. Stafford PR, Norris BL. Reamer-irrigator-aspirator bone graft and bi Masquelet technique for segmental bone defect nonunions: a review of 25 cases. Injury. 2010;41(suppl 2):S72–S77.
9. Taylor BC, Hancock J, Zitzke R, et al. Treatment of bone loss with the induced membrane
technique: techniques and outcomes. J Orthop Trauma. 2015;29:554–557.