Background: The purpose of this retrospective study was to analyze the long-term results of revision ORIF, joint contracture release, and autogenous bone-grafting in the treatment of distal humerus frac-ture nonunions in older aged patients with poor bone quality or bone loss who would have been candidates for total elbow arthroplasty. Methods: Seven patients (average age at index procedure: 53. 3 years, range: 41-75) with a distal humerus fracture nonunion treated with revision ORIF, joint contracture release and autogenous bone grafting between 1989-2000 were available for follow-up. Radiographic union and arthrosis were assessed using the most recent radiograph. Pain-related outcomes were measured using PROMIS Pain Interference scores. Functional outcomes were evaluated using the Mayo Elbow Perfor-mance Index (MEPI). Results: After an average follow-up of 22 years (range: 19-27 years), all nonunions were healed after the index procedure and had an average arc of ulnohumeral motion of 80° , flexion of 112° , and flex-ion contracture of 32° . Average arthrosis grade was moderate joint-space narrowing with osteo-phyte formation. One patient had exertional discomfort but none required chronic pain medica-tions. PROMIS-Pain Interference scores were no different than the general population (mean [95%CI] = 49. 2 [41. 8, 56. 6], P=0. 83). Per the MEPI, the functional result was excellent in five patients, good in one, and poor in one. Conclusion: Despite older age and worse bone quality, distal humerus fracture nonunions can be treated using revision ORIF, joint contracture release and autogenous bone-grafting with acceptable long-term outcomes.

Background: tibia is the most common bone to result in non-union after a fracture. Among the various approaches to non-union treatment, Ilizarov technique offers the advantage of simultaneous management of non-union, deformity bone defect and infection. We are reporting our results with such treatment in tibial non-union.Methods: 26 cases of tibial non-union that were treated with Ilizarov technique were evaluated clinically and radiographically in a retrospective manner, with and average follow-up of one year (7-21) months 12 cases were infected, 14 non-infected non-unions.Results: union was achieved in all the cases with a mean duration of 4 months (3-10 months). Pintract infection was observed in 6 cases. 2 required change of pintract, and one case of severe cellulites needed earlier discontinuation of Ilizarov fixation and use of cast brace which resulted in union. One case of knee and one ankle stiffness were observed.Conclusions: Ilizarov technique is a reliable method for treatment of tibial non-union, and is specifically useful for complicated cases.

Background: Several treatment approaches are now considered to manage tibial and femoral shaft nonunion after primary surgeries. Double-locking plates with channel bone grafting technology are treatments that surgeons could choose. We aimed to describe our experiences in evaluating the union of bone for these patients after using double-locking plates with channel bone grafting with serial examinations and radiologic studies. Methods: This case study was conducted on 33 patients consisting of 20 femoral nonunion and 13 tibial nonunion cases. They underwent double plate fixation with bone grafting at Sina Hospital, Tehran, Iran, from 2015 to 2020. They were monitored for an average of 60 months after surgery. Results: Union was achieved in all the patients in a mean of 10. 03 months (range: 8-18 months). During patients’,follow-up, no plate and screw breakage, device loosening, deformity, and infection were seen. No additional surgery was needed for any of our patients. Conclusion: There are various treatment options for nonunion of long bones. This study described the double plating approach for treating femoral and tibial shaft nonunion. The technique of double plate fixation and bone grafting had reasonable union rates in long bone nonunion. The present case series analysis also shows that it is more beneficial to manipulate this promising method for long bone nonunion whenever possible.

Background: Scaphoid is the most common carpal bone to fracture, and non-union is the most common complication of scaphoid fracture. The vascularized bone grafting, based on pronator quadratus muscle for scaphoid non-union is an option for a more successful union. We would like to report our experience. Methods: In a descriptive study between 2003 and 2004, 11 patients with scaphoid nonunion were operated on with pronator quadratus vascularized bone graft. The mean age of the patients was 22.9 years (18-29) and the duration of non-union was 12.2 months (6-24). The patients were evaluated clinically and radiographically after 6 months. Results: Union was achieved in 10 out of 11 patients. The mean time to union was 12 weeks. The mean pain score in the patients with union was 3.8 before and 1 after surgery. Seven patients had no activity related pain and 3 others experienced minimal exertional pain. There was no instance of fixation failure or substantial loss of reduction. The mean final range of motion of the wrist was 19° extension, 15° flexion, 5° radial deviation and 10° ulnar deviation. Final assessment of pain relief, improved motion and increased wrist function was excellent in 5 patients, good in 3 and fair in 2 patients.Conclusions: Pronator quadratus vascularized bone graft is an effective method for treatment of scaphoid nonunion, leading to rapid union and good wrist function, although it is a bigger surgery and takes longer to perform.

Objective: Nonunion is defined as a minimum of 9 months since injury without any visible progressive signs of healing for 3 months. Recent literature has shown that the application of mesenchymal stromal cells is safe, in vitro and in vivo, for treating long bone nonunion. The present study was performed to investigate the safety of mesenchymal stromal cell (MSC) implantation in combination with platelet lysate (PL) product for treating human long bone nonunion.Materials and Methods: In this case series clinical trial, orthopedic surgeons visited eighteen patients with long bone nonunion, of whom 7 complied with the eligibility criteria.These patients received mesenchymal stromal cells (20 million cells implanted once into the nonunion site using a fluoroscopic guide) in combination with PL product. For evaluation of the effects of this intervention all the patients were followed up by taking anterior-posterior and lateral X-rays of the affected limb before and 1, 3, 6, and 12 months after the implantation. All side effects (local or systemic, serious or non-serious, related or unrelated) were observed during this time period.Results: From a safety perspective the MSC implantation in combination with PL was very well tolerated during the 12 months of the trial. Four patients were healed; based on the control X- ray evidence, bony union had occurred.Conclusion: Results from the present study suggest that the implantation of bone marrow- derived MSCs in combination with PL is safe for the treatment of nonunion. A double blind, controlled clinical trial is required to assess the efficacy of this treatment (Registration Number: NCT01206179).

Proximal bumerus fractures- a common occurrence in elderly- comprise 4-5% of skeletal fractures. Twenty percent of such fractures require surgical treatment.Presence of painful movement at fracture site, 2-3 months after treatment, is called non- union. “Malunion” is the name given to a fracture with over 40 degrees rotation and or angulations or more than 10 millimeters displacement. The fracture pattern, age and personality of the patient and previously rendered treatment are the elements which determine the occurrence of malunion or nonunion.Good clinical evaluation, high quality standard radiographs and other imaging modalities like computerized tomography are mandatory for a successful treatment plan. Painful, limited range of motion fixation and bone grafting of a nonunion or osteotomy for malunion should be individualized according to patient’s complaint and functional demands.The results of implant arthroplasty are better for acute fracture than old healed malunions or nonunion. Prevention of non- nuion or malunion is superior to secondary reconstructive surgeries; and reconstruction outcome is dependent on meticulous planning and technique and patient selection.

Background: Tibial and femoral nonunion is not unusual after intramedullary fixation and might lead to multiple surgical procedures and long-term disabilities. Different surgical techniques have been described for management of lower limb long bone nonunion primarily treated with intramedullary nailing. Despite the use of various procedures, the success rate of most of them are suboptimal, increases the risk of related complications and costs. Objectives: Augmented plating concomitant with autologous bone grafting technique make it possible to improve healing in a single operation. Methods: In this study, 19 patients with lower limb long bone nonunion were primarily fixed with intramedullary nails, were treated with augmented plating and autologous bone grafting and followed for one year. Results: The union rate was 94. 7% with a mean union time of 4. 75 months, 18 patients healed completely with solid union and only one case of femoral shaft nonunion remained. Infection and other surgical-related complications were not detected. After one year follow up, Visual Analog Scale was 31 ± 18. 8, and decrement in active knee range of motion was more than 20% compared with opposite side in 47. 4% of the patients. Conclusion: According to the results, the single stage augmented plating with locking plates combined with autologous bone grafting can be used as a useful method in treatment of femoral or tibial nonunion.

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: Partial fibulectomy has been suggested for patients who encounter with severe varus/valgus or ununited fractures of the tibia. This study develops a finite element (FE) model of partial fibulectomy to study stress distribution in the tibiofemoral joint. Materials and Methods: A 3D magnetic resonance imaging (MRI)-based of tibiofemoral joint and FE model was developed for study from a man volunteer with the normal left knee. Components consisted of the exact geometry of femur, tibia, fibula, meniscus, and articular cartilages. Firstly, geometries were constructed in Mimics and then exported to Rapid Forming XOR2 and finally, the Computer-aided design (CAD) model was analyzed in ABAQUS 6. 10. Mechanical properties of the model for soft tissues were considered to be linear elastic, isotropic and homogenous and for bony parts were considered to be rigid. Results: Model predictions were compared with normal one and used to derive stress distribution under physiological loading for standing in quasi-static condition. The results showed load transferring toward lateral condyle due to partial fibulectomy. The variation of stress distribution would increase the risk of osteoarthritis. Conclusion: Our results have been predicted that partial fibulectomy could be an unknown risk factor for osteoarthritis and the model could be used for extended similar studies.

Background and Aim: Ununited fracture of tibia complicated by infection is not only a complex surgical problem but also a chronic and debilitating condition for patient and time-consuming problem for physician. Although traditional management results with success at times, it seems with Ilizarove external ring fixator we could achieve excellent results.Materials and Methods: From 1997 to 2004 these authors managed 84 patients with infected tibial nonunion in three teaching hospitals in Mashhad. There were 68 males and 16 females, with an average age of 26±1:8 years (17 to 55 years). The average time of follow-up was 3.5 years (range 3-9 year).Results: In 81 (96.42%) patients we achieved union and eradication of infection. The average time in frame was 6.4 months. Three patients (3.42%) eventually underwent below knee amputation because of refractory and persistent infection or other problems. We faced pin tract infection and loosening in 18 patients for 41 pins. We had 10 patients (11.9%) with neuropraxia of the proneal never which improved simultaneously but no long standing neurologic deficit. Only one patient with false aneurysm of anterior tibial artery happened which underwent vascular surgery. The most common long standing morbidity following this treatment was foot and ankle stiffuess and deformity especially in distal third cases.Conclusion: The Ilizarove technique for complex infected nonunion of tibia has a high rate of success in achieving union and eradication of infection. It is the only way, which we can advice the patient to be treated successfully strongly and surely.