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: 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.

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).

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.

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.