Bone grafting via reamer-irrigator-aspirator for nonunion of open Gustilo-Anderson type III tibial fractures treated with multiplanar external fixator

Abstract

Introduction: The purpose of this investigation was to evaluate the outcomes following reamer-irrigator-aspirator (RIA) autogenous bone grafting (ABG) of high-grade open tibia fracture nonunions stabilized via multiplanar external fixation.

Methods: We retrospectively reviewed all patients with Gustilo-Anderson type III open tibia fractures treated with multiplanar external fixation and who underwent RIA ABG for nonunion at our institutional Level 1 Trauma Center between 2008 and 2015. All patients between 15 and 65 years of age with a minimum of six-month follow-up were included. The primary outcomes of interest were achievement of union, time to union, and incidence of revision surgery. Complications and all-cause reoperation were recorded as secondary endpoints.

Results: Fifteen patients met the inclusion criteria with a mean age of 41.1 ± 14.0 years. RIA ABG was harvested from the femur in all cases, with a mean volume of 34 ± 15 mL. At an average follow-up of 13.3 ± 6.8 months, all patients achieved union, including two who required repeat RIA ABG. One patient experienced a femoral shaft fracture four months following RIA that required intramedullary fixation. The average time to union was 6.0 ± 6.3 months. Twelve patients (80%) went on to union within six months and 13 (86.7%) within one year. Five patients experienced a total of six post-operative complications including three deep infections, one refracture through the nonunion site, and one gradual varus deformity. Two patients in this series required a subsequent RIA autografting procedure secondary to persistent nonunion despite initial RIA.

Conclusion: We found that RIA ABG offered a reliable solution to nonunion of Gustilo-Anderson type III open tibial fractures treated with multiplanar external fixation, circumventing the need to change the method of fixation.

Figure 1.

Case example of a 49-year-old male polytrauma who sustained a Gustilo-Anderson grade IIIB open left proximal and distal tibial fractures following airplane crash. (A) Clinical images of large anteromedial wounds over the proximal and distal thirds of the leg with segmental bone loss distally, (B) anteroposterior and lateral injury radiographs demonstrating the aforementioned injuries with associated fibular fracture, (C) initial post-operative fluoroscopic images with Taylor Spatial Frame (TSF) in place, (D) coronal CT renderings of the distal tibial fracture at the time of nonunion (seven months following injury) with Taylor Spatial Frame in place, and (E) final film taken one year following RIA at the time of union and TSF removal.