Ninety-three patients with long bone non-unions or bone defects were randomized to receive either Reamer Irrigator Aspirator (RIA) bone graft (n=44) or autogenous iliac crest bone graft (AICBG; n=49). The primary outcome of interest was pain at the harvest site, measured by the visual analog score (VAS). Secondary outcomes of interest included the volume of graft obtained, union rates, reoperation rates, functional outcomes, and complications. Outcomes were assessed up to one year post-operatively. Overall, the results of the study revealed that the RIA group experienced significantly lower harvest site pain at one day post-surgery and obtained a significantly larger graft volume compared to the AICBG group. There were no significant differences in union rates, reoperation rates, complications, or functional outcomes between the two groups. These findings suggest that RIA bone grafting is a safe and effective alternative to AICBG, particularly for larger bone defects.