Case 1: RIA 2 use for bone grafting at the tibia (provided by Brent Norris, Tulsa, US)

A 59-year-old man working for the city of Tulsa suffered an open distal tibia plafond fracture on the left leg when he fell into a sewer hole with raw sewage (Fig 1). The wound was grossly contaminated, and he was taken immediately to the operating room (OR) for incision and drainage and application of a spanning external fixator. Bone loss was noted anterior and medial (about 2.5 or 3 cm) but only about 2025% of the bone circumference.

After repeated incision and drainage, 2 days later the fracture was repaired with an anterior lateral tibial plafond plate (Fig 2). Vancomycin and tobramycin impregnated antibiotic beads were placed in the bone defect.

The patient was discharged on hospital day 6 to a rehabilitation facility with his left lower extremity in a splint and touch down weight bear allowance. He returned 2 weeks later with drainage from the medial traumatic wound. In addition, he had a gastrointestinal bleed from use of nonsteroidal antiinflammatory drugs. Once the gastrointestinal bleed was stabilized, he was taken the next day to the OR for another incision and drainage. Further, more significant, devitalized bone was resected, and an antibiotic cement spacer was placed (Fig 3). Deep culture samples were taken despite knowing the antibiotic resorbable beads had been placed in the wound at the time of initial closure. The plate was left in place, but a planned exchange plate/nailing was to be performed pending final culture results.

Cultures eventually yielded Klebsiella pneumoniae and Enterobacter cloacae. The patient was administered intravenous antibiotics for 6 weeks and was discharged home with therapy and nursing. He returned to the clinic with wound breakdown and an exposed cement spacer at 10 weeks after injury. Further bone debridement, spacer exchange, repeated culture samples, and plastic surgery were undertaken to help with wound coverage with a rotational flap. The microbiological culture was still positive for Klebsiella pneumoniae.

Two months later, the patient had a staged cement spacer removal and hardware removal followed by a new spacer placement (Fig 4). When microbiological cultures were negative for 5 days he was taken to the OR for definitive fixation and bone grafting. RIA bone graft from the ipsilateral femur was taken, a new anterior lateral plate was placed with an adjunct IM nail (and angle stable screws) as the distal plafond was now one articular block (Fig 5).

The patient has been followed up monthly for more than 5 months and has shown continued consolidation of the bone defect (Fig 6). Furthermore, he is weight bearing as tolerated without significant pain. The leg lengths are equal and the range of motion at the ankle is 10/25 dorsiflexion/plantarflexion. He has mild pain over the ankle joint but no pain at the fracture site.

Case 2: RIA 2 use at the humerus (provided by Mark Lee, Sacramento, US)

The patient was an 83-year-old right-hand dominant man who sustained a closed right humeral shaft fracture approximately 10 months before presentation. He was not initially offered surgical care and was treated with functional bracing. The patient has moderate pain but mainly complains of instability and lack of strength in his right arm. He was offered surgical nonunion repair with autogenous iliac crest bone grafting but declined iliac crest harvest. X-rays showed oblique nonunion with resorption and confirmed diagnosis of pseudarthrosis (Fig 7).

After debridement and resection of the pseudarthrosis, we accessed the distal segment of the humeral canal and used a small caliber RIA 2 reamer head to harvest intramedullary bone graft (Fig 8) for final plate fixation (Fig 9).