Utilizing reamer irrigator aspirator (RIA) autograft for opening wedge high tibial osteotomy: A new surgical technique and report of three cases☆

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Abstract

INTRODUCTION

The lateral closing wedge high tibial osteotomy (HTO) was popularized by Coventry in the 1960s. In the 1990s the medial opening wedge osteotomy gained popularity because it could achieve greater valgus correction and it did not require dissociation of the fibula from the tibia, an important consideration when treating varus knees with lateral and posterolateral ligament deficiencies (Noyes’ double-varus and triple-varus knees). However, it has the disadvantage of requiring bone graft to fill bony defects. Recently, the reamer-irrigator-aspirator (RIA; Synthes, Paoli, PA) system was developed, and as a result of this procedure, a large amount of usable autogenous bone graft can be collected safely for use. To our knowledge, there is no published series combining opening wedge HTO with the use of RIA obtained autogenous bone graft.

PRESENTATION OF CASE

We present a novel technique in which a series of three patients underwent opening wedge HTO using ipsilateral, retrograde femur RIA graft to fill the bone defect. All patients had satisfactory clinical and radiologic outcomes following the new technique at latest follow up.

DISCUSSION

Opening wedge high tibial osteotomy is a well-documented and accepted orthopedic procedure, however, has the disadvantage of requiring varying amounts of bone graft. Traditionally, iliac crest or tricortical allograft have been the grafting modalities of choice, however both have inherent drawbacks to their use. In our series, the use of RIA autograft is a safe and reliable harvest technique for high tibial osteotomy, providing abundant and quality autogenous bone graft.

CONCLUSION

All three of our patients achieved radiographic union with high clinical patient satisfaction without any major complications. We feel this novel technique is a safe and acceptable operative solution grafting opening wedge osteotomies about the knee.

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Most cited references 14

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Complications following autologous bone graft harvesting from the iliac crest and using the RIA: a systematic review.

Rozalia Dimitriou, George I Mataliotakis, Antonios Angoules … (2011)

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the 'gold standard' and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate. Copyright © 2011 Elsevier Ltd. All rights reserved.

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Autogenous iliac crest bone graft. Complications and functional assessment.

Patricia Greenfield, L Senunas, G DeSilva … (1997)

Functional outcomes and complications experienced by adult patients who underwent iliac crest bone grafting were evaluated to assess the effect of bone grafts on patient function. In addition to retrospective chart reviews, patients completed the Sickness Impact Profile and a detailed questionnaire on pain. One hundred ninety-two patients met study inclusion criteria. Major complications were recorded in four (2.4%) patients in whom infections developed requiring readmission. Thirty-seven (21.8%) patients had minor complications. One hundred nineteen of 170 patients were available for followup; of these 119 patients, 87 (73.1%) returned completed questionnaires. Thirty-three of 87 (37.9%) patients reported pain 6 months postoperatively. The incidence of pain decreased with time, with 16 of 87 (18.7%) patients continuing to report pain more than 2 years postoperatively. Proportionately more spine patients reported pain at all time points. The mean Sickness Impact Profile score for patients completing questionnaires was nine, suggesting most patients were functioning well 2 years postoperatively. The morbidity of iliac crest grafting remains substantial. Pain symptoms in this study sample seemed to last longer in more patients than earlier series have indicated. Minimizing muscle dissection around donor sites and the advent of bone graft substitutes may help alleviate these problems.

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Iliac crest bone graft harvest donor site morbidity. A statistical evaluation.

Linda Asher, J C Banwart, R Hassanein (1995)

This study analyzed the cause, rate, and risk factors of iliac crest bone graft donor site morbidity. All complications or problems, no matter how small, were sought to develop strategies of prevention. A wide range of major, 0.76% (Keller et al) to 25% (Summers et al) and minor complications, 9.4% (Keller et al) to 24% (Summers et al) has been reported. A consecutive series of 261 patients, whose bone graft harvest was done by one surgeon, was studied by chart review and a mail survey that was not conducted by the operating surgeon. The survey presented specific open-ended questions designed to uncover any complication/problem, no matter how small. Complications then were categorized as major or minor and subcategorized as acute or chronic. Statistical analysis was done using chi-squared and multiple logistical regression. None of the 261 patients had a severe perioperative complication--e.g., superior gluteal artery injury, sciatic nerve injury, or deep wound infection. None of the 225 patients with long term follow-up (average, 66 months; range, 32-105 months) had a severe late complication--e.g., donor site herniation, meralgia paresthetica, pelvic instability, or fracture. Of the 180 patients meeting the qualifications for statistical analysis, major complications occurred in 18 (10%), only three of which affected function (pain). Minor complications occurred in 70 (39%). The results indicated that severe complications from iliac crest bone graft harvest can be avoided and major complications affecting functioning are uncommon, but minor complications are common. The findings suggest that procedural refinements of limiting subcutaneous dissection and providing layered tension-free incision closure may improve results.

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Author and article information

Contributors

Richard A. Seagrave

John Sojka

Adam Goodyear

Stephen W. Munns

Journal

Journal ID (nlm-ta): Int J Surg Case Rep

Journal ID (iso-abbrev): Int J Surg Case Rep

Title: International Journal of Surgery Case Reports

Publisher: Elsevier

ISSN (Electronic): 2210-2612

Publication date PMC-release: 15 November 2013

Publication date (Electronic): 15 November 2013

Publication date Collection: 2014

Volume: 5

Issue: 1

Pages: 37-42

Affiliations

[0005]University of Kansas Medical Center, Department of Orthopedics, 3901, Rainbow Boulevard, Kansas City, KS 66160, United States

Author notes

[* ]Corresponding author. Tel.: +1 913 588 5000. rseagrave@ 123456kumc.edu

[1]

Tel.: +1 913 588 5000.

Article

Publisher ID: S2210-2612(13)00331-3

DOI: 10.1016/j.ijscr.2013.11.004

PMC ID: 3907197

PubMed ID: 24412805

SO-VID: f4a1cf29-99ce-4abc-b899-27ea68f19a1c

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 28 May 2013

Date revision received : 25 August 2013

Date accepted : 5 November 2013

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Complications associated using the reamer–irrigator –aspirator (RIA) system: a systematic review and meta-analysis
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