Nonunion of tibial stress fracture has been reported in athletes and only in proximal and midshaft of tibia. We have found no report of nonunion of a stress fracture in distal tibiofibula. Report of this lesion, especially in a non-athlete adolescent, is interesting and important.

Background: Nonunion of distal radius fractures is disabling. Treatment is difficult and the results are not predictable. However, posterior interosseous bone flap (PIBF) has been successful in treating forearm nonunion. Objectives: To treat distal radius fracture nonunion with PIBF as a new procedure. Patients and Methods: This prospective non-randomized cohort study was performed at two hospitals in Tehran between January 2011 and September 2015. PIBFs were applied in nine patients (10 nonunions) with a mean age of 55 years. Union success rate, grip strength, wrist range of motion, and forearm rotation were then evaluated. Results: Although four of the patients had a history of infection, all participants achieved fracture union at a mean time of 3. 8 months. Grip strength improved by 12. 4 kg. There was also 36° improvement in wrist flexion, 20° improvement in wrist extension, 60° improvement in forearm supination, and 46° improvement in forearm pronation. The range of motion and grip strength improvements were significant. Conclusions: Pedicled PIBF is a new option for treating distal radius fracture nonunion. The results are predictable in achieving union and good function, and this technique can be successfully used in cases with extensive soft-tissue damage or infection.

Objective: Nonunion fracture of lower-extremity long bones is really important because these bones bear the weight of the body. Some reasons of nonunion fracture are: Instability and immobility of the fractured fragments; insufficient blood supply to the fractured site; and damage to periosteum and necrosis of periosteal cells caused by insufficient blood supply. There are two methods of nonunion treatment based on Iranian traditional medicine: (A) Nonsurgical treatment including physiotherapy, ultrasonic or electromagnetic waves or injection of Maltose-binding protein for stimulation of bone regeneration; and (b) Surgical treatment with the aim of fixing fractured parts internally and externally, and eventually bone graft in the form of allografts and autografts. Methods: The patient was a 29-year-old man whose thigh bone had been fractured in an accident at the age of 21. During 8 years, he had underwent surgical and nonsurgical treatments as well as allograft and autograft transplantation, but unfortunately none of these treatments were effective and he suffered from infection, transplant rejection and necrosis of fractured fragments. Disappointed patient was subjected to treatment based on traditional medicine including modification of lifestyle and dietary regime, and using traditional drugs and leech therapy. Conclusion: After 6 months of therapy, avascular necrosis was completely removed and new bones were created in the areas between the fractures and the patient got better over time. By expanding education and research in the field of Iranian traditional medicine, we can increase the use of effective, noninvasive and low-cost Iranian-based therapies which have great role in improving the quality of life of the individual and community and can prevent from expensive material and spiritual costs of surgery and amputation.

Abstract Background: Nonunion is a serious complication following long-bone fracture that is known as a therapeutic challenge for surgeons and is associated with significant morbidity. It has been shown that osteogenesis stimulating factors combined with optimization of the mechanical environment could facilitate and accelerate nonunion healing. In this study, we aimed to treat nonunion using autologous bone marrow-derived mononuclear cell (BMDMC) aspirate as a source of osteoprogenitor cells combined with internal fixation. Methods: From November 2010 to May 2013, 19 cases of nonunion were treated with bone marrow-derived mononuclear cell (BMDMC) grafting, that included 15 males and 4 females with an average age of 37. 8 years (range, 18-81 years). The time from injury to therapy was 7 to 28 months, with an average of 13. 4 months. At first, decortications were performed around the nonunion site to prepare a suitable bed for bone marrow grafting. Then, 2 ml of bone marrow concentrated cells was applied to the nonunion site in a mixture with partially demineralized cortical cancellous allograft chips. The healing rate in each patient was clinically and radiologically evaluated every 4 weeks. Results: Bone union was obtained in 18 of the 19 patients during 1. 06 to 6 months with an average time of 3. 5 months. No complications during anesthesia nor any infection, hematoma or chronic pain at the nonunion site were observed in any patient. Conclusion: Transplantation of autologous BMDMC aspirate is a reasonable, effective and easy treatment option for tibial and femoral nonunion after internal fi xation.

Introduction: The humerus shaft fracture (HSF) is a typical long bone fracture. Following non-surgical therapy, some patients experience delayed or non-union of the HSF. The most common treatment is open reduction and internal fixation (ORIF) with plate and bone graft. However, substantial tissue dissection increases radial nerve damage and delays union. Because of its minimally invasive nature, the minimally invasive plate osteosynthesis (MIPO) method may be a suitable replacement technique. MIPO helps to the protection soft tissue and nerves in the area of the fracture. A better and faster union with less tissue dissection or vascular disturbance are achieved. Methods: All patients were treated with the MIPO method using bone graft implantation. A special six-hole locking plate was used. Physical examinations and radiological studies were used to monitor the patients' progress. UCLA and the MEPS scoring system assessed shoulder and elbow function. The average follow-up period was six months. Results: The mean age of patients was 39. 8 years (19-73 years). The mean fracture site distance from the elbow joint was 12. 1 cm. The mean maximal final rotation was 3. 3 degrees. The last rotation alignment was within normal limits. No shortening was detected. Average scores were 35 for UCLA and 100 for MEPS. Radial nerve damage was not reported. Malunion, delayed union, or nonunion did not occur. Mean union time was 2. 8 months. Conclusion: MIPO technique combined with bone graft causes micromotion at the fracture site, resulting in a better and faster union. Its minimally invasive nature also helps prevent iatrogenic injury to nerves and soft tissue. Less tissue manipulation and dissection help shoulder and elbow function progress more quickly and reduce the rate of malunion. We recommend using this method in delayed union and nonunion of the HSF patients for better outcomes and less complications.

Statement of Problem: In a previous study it was reported that a durable resin-ceramic tensile bond could be obtained by an appropriate silane application without the need for HF acid etching the ceramic surface. Evaluation of the appropriate application of silane by other test methods seems to be necessary.Purpose: The purpose of this study was to compare the interfacial fracture toughness of smooth and roughened ceramic surfaces bonded with a luting resin.Materials and Methods: Ceramic discs of 10 mm in diameter and 2 mm in thickness were prepared.Four different surface preparations (n=10) were carried out consisting of (1) ceramic surface polished to a 1µm finish, (2) gritblasted with 50µm alumina, (3) etched with 10% HF for 2 min, and (4) gritblasted and etched. The ceramic discs were then embedded in PMMA resin. For the adhesive area, the discs were masked with Teflon tapes. A circular hole with diameter of 3 mm and chevron-shaped with a 90° angle was punched into a piece of Teflon tape. The exposed ceramic surfaces were treated by an optimised silane treatment followed by an unfilled resin and then a luting resin cylinder of 4mm in diameter and 11 mm in length was built. Specimens were stored in two different storage conditions: (A): Distilled water at 37°C for 24 hours and (B): Distilled water at 37°C for 30 days. The interfacial fracture toughness (GIC) was measured at a cross-head speed of 1 mm/min. The mode of failure was examined under a stereo-zoom microscope and fracture surfaces were examined under Scanning Electron Microscope.Results: The mean interfacial fracture toughness values were; Group A: 1) 317.1±114.8, 2) 304.5±109.2, 3) 364.5±169.8, and 4) 379.4±127.8 J/m2±SD. Group B: 1) 255.6±134.4, 2) 648.0±185.1, 3) 629.3±182.6 and 4) 639.9 ±489.0 J/m2±SD. One way Analysis of Variance showed that there was no statistically significant difference in the mean interfacial fracture toughness for groups A1-A4 (P>0.05). However, the mean interfacial fracture toughness for group B1 was significantly different from that for groups B2, B3 and B4 (P<0.05). Independent-ٍٍٍSamples T-Test results showed that there was a significant increase in the GIC mean value for groups B2 and B3 after 30 days water storage (P<0.05). The modes of failure were predominantly interfacial or cohesive within the resin.Conclusions: The fracture toughness test method used in this study would be appropriate for analysis of the adhesive zone of resin-ceramic systems. From the results, it can be concluded that micro-mechanical retention by gritblasting the ceramic surfaces could be sufficient with no need for HF acid etching the ceramic surfaces when an appropriate silane application procedure is used.

Background and purpose: Nonunion of bone fracture is a clinical and treatment challenge. Satisfactory repair of orthopedic fractures is of great importance and systemic treatment is used to achieve this goal. This study aimed to investigate the effect of Teriparatide (CinnoPar® ) on nonunion fractures. Materials and methods: A quasi-experimental study was conducted in 17 patients with nonunion bone fractures. Radiographic evaluation was performed before the intervention and nonunion was confirmed by a radiologist. Then, all patients received Teriparatide for three months. Afterwards, a control x-ray image was taken to assess the outcome. Results: Sixteen patients (mean age: 45. 18± 20. 51) with nonunion fracture were evaluated, including nine males and seven females. The mean time after the accident was 50 ± 24. 48 weeks. Femoral bone was the most reported impaired site (n=8). After treatment with Teriparatide (CinnoPar® ) improvements were seen in 10 patients (P= 0. 002). Conclusion: Treatment with CinnoPar® was found to be effective to some extent. However, due to the small sample size in this study, the efficacy of CinnoPar® needs further assessments.

Objectives: Non-repairable scaphoid proximal pole nonunion remains a major challenge. Various reconstructive surgical approaches have been introduced, but each one has some limitations, including microvascular anastomosis, donor site morbidities, and the risk of compromising the scapholunate ligament. Methods: This prospective interventional case series was performed on five patients. The patients underwent reconstructive surgery using proximal hamate arthroplasty by a single surgeon and were followed up for at least 12 months. Results: All patients were male and the median age was 28, and the median follow-up time was 24 months. The median Mayo score was 70, and the DASH score was 0 (no disability) in 3 patients and 15 in two patients. The median of postoperative grip strength in the operated hands was 37. 3 kg (Range 36. 1–39) and in the opposite hands was 42. 5 kg (Range 40–45. 9). However, there were significant differences between grip strength between operated and opposite hands (P value= 0. 008). A reduction of 11. 1% and 15% was shown in postoperative flexion and extension compared with preoperative flexion and extension (P value = 0. 194, P value = 0. 102). Conclusion: Hamate arthroplasty for nonunion of the scaphoid proximal pole appears to be a viable surgical option with favorable outcomes in terms of union rates, functional recovery, and patient satisfaction. Level of evidence: IV

Background: Femoral neck nonunion could be a disaster in young and middle age patients. Conventional valgus osteotomy of femur is done without freshening of nonunion site. We would like to report our experience with valgus osteotomy of hip after freshening of the nonunion site.Methods: In a case-series study, from all young and middle-aged patients with nonunion femoral neck fracture who were treated with freshening of nonunion site and valgus osteotomy, 22 patients (18 males, 4 females) with mean age of 34 (20-47) entered the study. There were 10 broken implants in the heads with a one year follow-up. The cases were evaluated for union, necrosis and also changes in Harris hip scores.Results: Preoperative Harris hip score was 63 and postoperative score increased to 89. The neck shaft angle was reached about 150 degrees. In 2 cases necrosis developed and in 3 cases collapse of neck occurred with intrusion of implant into the joint and the implants were removed immediately. Mean time to union was 4.5 months.Conclusion: Freshening of nonunion site before valgus osteotomy in nonunion femoral fracture produces high union rate with low complications.