Aseptic Nonunion Research Articles

Dynamic Contrast-Enhanced Sonography and Dynamic Contrast-Enhanced Magnetic Resonance Imaging for Preoperative Diagnosis of Infected Nonunions.

Bone regeneration depends on perfusion of the fracture tissue, whereby hypervascularity is associated with infection, which itself causes nonunions. To date, nonunion perfusion has not been assessed with contrast-enhanced sonography. The aim of this study was to evaluate the potential of contrast-enhanced sonography in the analysis of nonunion tissue perfusion. Nonunion vascularity of 31 patients before revision surgery was prospectively examined with qualitative contrast-enhanced sonography and dynamic contrast-enhanced magnetic resonance imaging (MRI). Time-intensity curves from 2-minute contrast-enhanced sonographic video clips were generated, and parameters such as wash-in rate, rise time, and peak enhancement were quantified. On dynamic contrast-enhanced MRI, the initial area under the enhancement curve was quantified. Preoperative radiographs, computed tomograms, the clinical nonunion score, laboratory infection features, as well as contrast-enhanced sonographic and dynamic contrast-enhanced MRI perfusion were correlated with microbiological results from the nonunion tissue. Both qualitative and quantitative contrast-enhanced sonography showed significant differences between infected and aseptic nonunions (P = .015 and .020). The qualitative dynamic contrast-enhanced MRI analysis was not significant (P= .244), but after quantification, a strong correlation (P = .007) with microbiological results was noted. A receiver operating characteristic analysis calculated ideal cutoff values for quantitative contrast-enhanced sonography and dynamic contrast-enhanced MRI so that their combination detected infected nonunions with sensitivity and specificity of 88.9% and 77.3%, respectively. Clinical, radiologic, and laboratory examinations did not correlate with microbiological results (P > .05). Contrast-enhanced sonography can visualize the vascularity of nonunions in real time, while quantification software allows for a semiobjective evaluation of bone perfusion. The correlations of both quantitative contrast-enhanced sonography and dynamic contrast-enhanced MRI with microbiological results show their high value for differentiation of infected from aseptic nonunions.

Addition of a Medial Locking Plate to an In Situ Lateral Locking Plate Results in Healing of Distal Femoral Nonunions.

Nonunion of the distal femur after lateral plating is associated with axial malalignment, chronic pain, loss of ambulatory function, and decreased knee ROM. The addition of a medial locking plate with autogenous bone grafting can provide greater stability to allow bone healing and may be used to achieve union in these challenging cases. We wished to determine (1) the proportion of patients who achieve radiographic signs of osseous union for distal femoral nonunions with an in situ lateral plate after treatment with addition of a medial locking plate and autogenous bone grafting, and (2) the frequency and types of complications associated with this treatment. Between 2007 and 2013, we treated 22 patients for 23 distal femoral nonunions, defined as an unhealed fracture with no radiographic signs of osseous union at a mean of 16 months (SD, 13 months) after injury. During that time, we used a treatment algorithm consisting of treatment in one or two stages. The single-stage procedure performed in 16 aseptic nonunions with a stable lateral plate involved addition of a medial locking plate and autogenous bone graft. A two-stage treatment performed in seven nonunions with lateral plate failure involved placement of a new lateral locking plate followed by addition of a medial locking plate with autogenous bone graft at least 2 months after the first procedure. Of the 22 patients treated, 20 had a median followup of 18 months (SD, 6-94 months). We defined osseous union by bridging bone on three of four cortices with absence of a radiolucent line or more than 25% cross-sectional area of bridging bone via CT. Twenty of the 21 nonunions attained radiographic signs of osseous union by 12 months. Six of the 20 patients experienced complications: one patient had a persistent nonunion; four patients underwent removal of symptomatic hardware; and one patient experienced skin breakdown at the bone graft harvest site. A very high proportion of patients achieve union when using medial locking plates to treat distal femoral nonunions after lateral plating of the original injury. Addition of bone graft, staged reconstruction, and revision of the initial lateral plate is indicated when the nonunion is associated with fatigue failure of the initial lateral plate. Level IV, therapeutic study.

Non union long bones treated with rigid fixation and autogenous bone grafting. A Series of 50 Cases

Introduction: The surgical treatment of aseptic nonunion often represents a more challenging situation for the orthopaedic surgeon than treatment of the primary fracture. In fact, it may be necessary not only to ―rivitalize‖ the nonunion area, but also to exchange the bone fixationdevices and to place some refill material in the bone gap. Objective: To study the Non-union long bones treated with rigid fixation and autogenous bone grafting. Materials and methods: We present the results of 50 cases of long bone nonunion that have been treated in a period of 3 years (2011–2013) by open approach to the nonunion site with autologous bone graft interposition. The site 11humerus, 9 forearms, 12 femurs, 18 tibias and the type of nonunion (42 atrophic, 8 hypertrophic) was considered in the surgical planning as were the mechanic and biological problems. Newosteosynthesis was performed in50 cases: with plate and screws in 29 cases, with intramedullary nails in 16 cases, with external fixators in 2 cases and with only bone grafting in 3 cases. Bone graft, always autologous from the iliac crest was used in 48 cases and fibula with iliac graft was used in 2 cases. Result: Healing of the nonunion was successful in 49cases in a mean time of 9.8 weeks with few complications which was easily manageable and did not hinder the functional result. Conclusion: Autogenous Cortico-Cancellous Bone graft & Rigid Fixation still Gold Standard Treatment for Non-Unions in the era of Vascularised Bone Grafts.

The treatment of atrophic, recalcitrant long-bone nonunion in the upper extremity with human recombinant bone morphogenetic protein-7 (rhBMP-7) and plate fixation: A retrospective review

IntroductionRecombinant Human Bone Morphogenetic Protein-7 (rhBMP-7) has been shown to promote fracture healing in both clinical studies and basic science models, however, there is little information from large-scale studies of its use for human nonunion. The purpose of this study was to determine the safety and efficacy of rhBMP-7 in the treatment of atrophic human long-bone nonunions in the upper extremity. Patients and methodsThis was a single center, retrospective, longitudinal cohort study of patients treated with compression plating and the application of rhBMP-7 in isolation to a long-bone nonunion. Patients over sixteen years of age with an atrophic, aseptic nonunion of a humerus, radius, ulna or clavicle were eligible for inclusion. ResultsWe identified seventy eligible patients who were treated with rhBMP-7 for a long-bone nonunion between July 1997 and April 2012. The mean age of the patients at the time of treatment with rhBMP-7 was 50.7 years (range, 20-92 years). Five patients were lost to follow-up prior to definitive clinical or radiographic union. During the one-year post-operative period fifty-six patients had achieved union and two patients developed a stable fibrous union after the index procedure. Two patients had early implant failure and five patients had persistent nonunion. Thus, the union rate following initial surgery was 89% (58/65) and four of the five nonunion patients went on to heal following revision open reduction and internal fixation. ConclusionWe found that the application of rhBMP-7 for upper extremity nonunion was an effective method (89% union rate) of treating this challenging pathology. Additionally, if not initially successful, further reconstruction was not compromised by rhBMP-7 use.

Aseptic nonunion of pediatric subtrochanteric fracture: A case report

Nonunion of pediatric fractures related to the extracapsular proximal femur is a rare event if managed appropriately. Varus malposition renders increased stress over the fracture site leading to failure of the sound union. Management of such fractures is difficult owing to limited implant choices and presence of adjacent open physes. Open reduction and freshening of edges, removal of fibrous tissue, internal fixation with intra, or extramedullary implants, and a compliant follow-up are keys to the good functional outcome.

Complication management for failed bone fracture healing: pseudarthrosis

Delayed fracture healing for more than 6-8 months is defined as non-union (pseudarthrosis). Non-unions are classifiable as septic, aseptic, hypertrophic and atrophic non-unions. In case of septic non-unions the infection is treated primarily followed by treatment of the delayed fracture healing. Aseptic non-unions may be treated non-operatively (e.g. shock wave therapy and/or ultrasound) or by various surgical strategies to stimulate bone regeneration and healing.

RhBMP-7 for the treatment of nonunion of fractures of long bones.

We report the outcome of 84 nonunions involving long bones which were treated with rhBMP-7, in 84 patients (60 men: 24 women) with a mean age 46 years (18 to 81) between 2003 and 2011. The patients had undergone a mean of three previous operations (one to 11) for nonunion which had been present for a mean of 17 months (4 months to 20 years). The nonunions involved the lower limb in 71 patients and the remainder involved the upper limb. A total of 30 nonunions were septic. Treatment was considered successful when the nonunion healed without additional procedures. The relationship between successful union and the time to union was investigated and various factors including age and gender, the nature of the nonunion (location, size, type, chronicity, previous procedures, infection, the condition of the soft tissues) and type of index procedure (revision of fixation, type of graft, amount of rhBMP-7) were analysed. The improvement of the patients' quality of life was estimated using the Short Form (SF) 12 score. A total of 68 nonunions (80.9%) healed with no need for further procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate logistic regression analysis of the factors affecting union suggested that only infection significantly affected the rate of union (p = 0.004).Time to union was only affected by the number of previous failed procedures (p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and mental score, respectively, was noted within the first post-operative year. Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion and improved quality of life in about 80% of patients. Aseptic nonunions were much more likely to unite than septic ones. The number of previous failed operations significantly delayed the time to union.

The value of 18-FDG PET/CT in the diagnosis and management of implant-related infections of the tibia: A case series

BackgroundPositron emission tomography (PET) combined with Computerised Tomography (CT) is gaining ground in clinical settings due to its added value of combined metabolic and anatomical imaging. PET/CT has shown promising results in diagnosing both acute and chronic infection of the axial and appendicular skeleton. PET imaging has an advantage in patients with metallic implants because FDG uptake, in contrast to magnetic resonance imaging (MRI) and standard computed tomography (CT), is not hampered by metallic artifacts. The role of PET/CT in the evaluation of implant-related infections involving the tibia in particular has not been thoroughly studied. PurposeTo investigate the usefulness of 18-FDG PET/CT in the diagnosis and treatment of implant-related infections of the tibia following osteosynthesis. MethodsWe reviewed 10 patients who underwent internal fixation to the tibia following trauma (4 open fractures, 6 closed fractures) and presented later with clinical signs of a possible implant-related infection. In evaluating the patients we used standard work-up methods (standard radiographs, lab tests) as well as advanced imaging techniques (PET/CT) in order to confirm the diagnosis and decide upon the preferred treatment. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were then calculated for PET/CTs ability to predict presence of infection using intraoperative cultures as the gold standard. ResultsPET/CT validated our working diagnosis 9 out of 10 patients. In particular, it helped distinguish between: infected nonunion (n=4), aseptic nonunion (n=1), soft tissue infection (n=2) and chronic osteomyelitis (n=3). The overall sensitivity and specificity of PET/CT for identifying an osseous infection were 85.7% and 100%, respectively. The PPV and NPV were 100% and 75%, respectively. ConclusionPET/CT is a promising imaging modality that can aid in the work up of patients with suspected implant-related infections of the tibia following osteosynthesis, and may be used as a supportive measure in clinical decision making.

Le pseudoartrosi nelle fratture diafisarie

Nonunion is one of the most challenging orthopaedic complications. The aim of our work was to make a diagnosis, classification and type of treatment of nonunions. The most important classification divides nonunions into aseptic and septic. The technique selected for treating aseptic nonunion depends on viability and alignment of the fragment. Therapeutic intervention aims at improving the mechanical and biological environment at the nonunion area. Circular fixation can play an active role in this kind of diseases.

Fixator-Assisted Femoral Lengthening Following Intramedullary Exchange Nailing for Subtrochanteric Non-union.

Non-unions in the femur can be a severely debilitating condition. When a non-union results in significant shortening and leg length discrepancy, simple activities of daily living become extremely difficult and painful tasks. Here, we present a 36 year-old male who presented three years following a motor vehicle accident, complaining of severe left thigh pain and a short left lower extremity. Initially treated in Egypt with an intramedullary nail (IMN) and distal screws, work-up revealed an aseptic subtrochanteric femoral nonunion with a leg length discrepancy of approximately 6.5 cm. The patient subsequently underwent exchange nail with rail fixator placement and was lengthened over the nail. After achieving adequate length, the patient underwent a second exchange nail, which was complicated by IMN instability. Due to the IMN instability, the patient underwent a third exchange nail with blocking screws, and finally healed. On final follow-up, the patient was pain free and no longer felt the leg length discrepancy, with an overall discrepancy of approximately 1.5 cm.

Bone marrow concentrate efficacy in treatment of chronic aseptic nonunion

Bone marrow concentrate efficacy in treatment of chronic aseptic nonunion

Bone Marrow Transplantation Followed by Growth Factors Injection in a Patient with Femoral Neck Nonunion: A Case Report

Background: Most fractures of femoral neck typically heal, but a significant proportion of fractures fail to heal, resulting in aseptic bone necrosis, delayed union or persistent nonunion. Specially, nonunion of fractured neck of femur in young adults is a serious problem. Some preclinical evidences show the therapeutic potential of autologous bone marrow for bone fracture healing; however, clinical outcome following of transplantation of bone marrow cells in patients with femoral neck nonunion has never been reported. Case description: We describe a 57-year-old male who had a femoral neck nonunion and received autologous bone marrow transplantation, followed by growth factors injection. The primary endpoint of this study is to achieve radiological fracture healing (union) by evaluating anteroposterior images taken after and on 6th month, following bone marrow therapy and no serious adverse event occurred. Literature review: To our knowledge, this is the first case in the literature of nonunion of femoral neck fracture treated with percutaneous autologous bone marrow transplantation. Clinical relevance: This case suggests that autologous bone marrow transplantation, followed by plasma rich in growth factors (PRGF) could be considered as an exciting option to treat nonunion in femoral neck fracture.

Reamed Interlocking Intramedullary Nailing For Open Fractures of Shaft of Tibia

Introduction: With rapid increase in day-to-day traffic, incidences of high-energy trauma are also increasing with the same speed. Open fractures of the tibial shaft are important for the reason that they are common & controversial. Our aims and objectives were to assess the time to bone union and functional outcome in cases of open fractures of the tibial shaft treated with reamed interlocking intramedullary nailing. Methods: Thirty patients who had 30 open fractures of the tibial shaft were treated with wound debridement and primary interlocking intramedullary nailing with reaming during the period from June 2012 to March 2014. The patients were followed up for a period of 6 – 14 months. Results: There were 9 (30 %) Type I fractures, 8 (27%) Type II fractures and 13 (43%) Type IIIA fractures. Mean time to union was 20.25 weeks for Grade I fracture, 22.5 weeks for Grade II, 24.71 weeks for Grade IIIA fractures. Deep infection occurred in 2 patients. Aseptic nonunion occurred in one patient. Malunion was noted in one patient. Interpretation and Conclusion: The results in the current study and other data support the view that reamed locked intramedullary nailing is a safe and effective technique for the management of open tibial fractures. Keywords: Open tibial fractures, Reamed nailing

Effectiveness of ilizarov frame fixation on functional outcome in aseptic tibial non-union cases at Abha, Kingdom of Saudi Arabia: An experimental study

Abstract Objectives The Objective of the study is to evaluate the effect of Ilizarov frame fixation on functional outcome in aseptic tibial non-union cases. Methods In this clinical study, 12 cases of post-traumatic aseptic tibial non-union were selected. After blood analysis and clinical assessment, the aseptic nonunion cases underwent ilizarov fixation for their problem. The pre and post-surgery functional outcome was measured by modified functional evaluation system by Karlstrom-Olerud. Results Out of the 12 patients, 3 females and 9 males, 5 had non-union of type A and were treated by compression technique. the other 7 had non-union of type B and were treated using bone-transport. Tibial union was achieved in all the cases. The functional outcome has shown 4 good, 2 satisfactory, 4 moderate and 2 poor. Conclusion The Ilizarov technique is an effective method in treating the aseptic tibial non-union.

Results of non-union of humerus treated with retrograde humeral nail.

Treating non-union of humerus fracture is a surgical challenge with variable outcome. We report series of 51 adult patients of aseptic non-union of humerus from 1998 to 2010 treated retrograde humeral nail. The mean age of patient was 54 years with 33 females and 18 males. The mean duration of non-union was 8 months. In 48 out of 51 cases (94 %), union was achieved at mean duration of 10.1 months. Thirty-two out of 51 patients needed bone grafting. Three patients had post-operative radial nerve neuropraxia which fully recovered. At last visit, mean Constant score for shoulder was 83 and mean Mayo score for elbow 78. Our series with this implant shows excellent union rates for extra articular humeral non-unions in adults.

Factors affecting the incidence of aseptic nonunion after surgical fixation of humeral diaphyseal fracture

Background Although aseptic nonunion of humeral diaphyseal fracture is rare, it often is debilitating for the patient. Treatment is challenging for the surgeon when nonunion occurs. The purpose of this study was to analyze and identify independent risk factors for aseptic nonunion among patients with humeral diaphyseal fracture undergoing surgical fixation.Methods The medical records of all humeral diaphyseal fracture patients who underwent surgical fixation from January 2005 to January 2011 were reviewed to identify those who developed aseptic nonunion. We performed univariate and multivariate logistic regression to identify independent associations of potential risk factors for aseptic nonunion among patients with surgical humeral diaphyseal fracture.Results A total of 686 patients were identified, with 659 meeting our inclusion criteria. Among these 659 cases there were 24 cases of septic nonunion, an incidence of 3.6 %. The patients were followed for 9–24 months, with an average follow-up period of 14.8 months. In the final regression model, advanced age (odds ratio, 1.09; 95 % CI: 1.03–1.14, P = 0.001), smoking (odds ratio, 5.34; 95 % CI: 1.05–27.00, P = 0.043), use of NSAIDs (odds ratio, 2.51; 95 % CI: 1.80–3.50, P < 0.001), and ASA score (odds ratio, 3.04; 95 % CI: 1.06–8.74, P = 0.039) were risk factors for aseptic nonunion of humeral diaphyseal fracture after surgical fixation.Conclusions This analysis confirms advanced age, smoking, use of NSAIDs, and ASA score were related to an increased risk of aseptic nonunion of humeral diaphyseal fracture after surgical fixation. Patients who have the risk factors identified in this study should be counseled about the possibility of aseptic nonunion occurring after surgical fixation.

Indolent infection in nonunion of the distal femur.

In the treatment of nonunions of the distal femur, infection should be excluded. However, it is difficult to determine whether the nonunion is infected or not with negative history and signs of infection. The purpose of this study was to investigate indolent infection as a cause of presumptive aseptic distal femur nonunion. All presumptive aseptic distal femur nonunions treated from 1998 to 2008 were retrospectively reviewed. Any patient with suspected of having an infection clinically was excluded. Multiple tissue cultures were performed at the nonunion site. The main outcomes were to analyze the rate of positive cultures in presumptive aseptic distal femur nonunion and to compare the rate of secondary surgery in positive and negative culture groups. Of the 22 patients, 3 (13.6%) had positive culture results. The organisms cultured were Staphylococcus aureus, Staphylococcus epidermidis, and Enterobacter cloacae. The overall rate of infection was 9.1% (2/22), and one patient underwent a secondary procedure. In the open fracture group, 2 of 10 patients (20%) had positive cultures; all developed infection. In the closed fracture group, 1 of 12 patients (8.3%) had positive culture results, but Infection did not occur in the patient with a 3-week intravenous antibiotic treatment. The postoperative infection rate was 67% (2/3) in patients with positive intraoperative cultures, while 0% (0/18) in the group with negative intraoperative cultures (p<0.001). The presence of indolent infection can be verified in patients with presumptive aseptic nonunion of distal femoral fractures by obtaining intraoperative biopsy tissue cultures. Positive intraoperative culture results were related with postoperative infection.

Primary Arthrodesis of the Tibiotalar Joint in Severely Comminuted High-Energy Pilon Fractures.

The treatment of highly comminuted tibial pilon fractures is controversial. The aim of this study was to determine the effectiveness and outcomes of primary arthrodesis following highly comminuted tibial plafond fractures. A database search was performed to identify all patients who underwent blade plate arthrodesis at our institution over a sixteen-year period. Inclusion criteria included patients with an Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association type-C2 or type-C3 pilon fracture that was deemed to be non-reconstructable by the treating surgeon. Outcomes were measured using the Short-Form 36-Item Health Survey, time to independent walking, time to consolidation of the arthrodesis, and wound-healing complications. A total of twenty patients were included in this study, and seventeen patients (85%) were available for follow-up at a minimum of two years after their surgery. Wound infections or wound dehiscence did not occur in this series. All patients were walking without crutches or a walker at their latest follow-up. One patient developed an aseptic nonunion and healed successfully after revision surgery. Blade plate ankle fusion using a posterior approach is a reliable method for the treatment of a small subset of patients with severely comminuted, non-reconstructable pilon fractures. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Adverse Event Rates and Classifications in Medial Opening Wedge High Tibial Osteotomy

Background: Previously reported complications in medial opening wedge (MOW) high tibial osteotomy (HTO) vary considerably in both rate and severity. Purpose: (1) To determine the rates of adverse events in MOW HTO classified into different grades of severity based on the treatments required and (2) to compare patient-reported outcomes between the different adverse event classifications. Study Design: Case series; Level of evidence, 4. Methods: All patients receiving MOW HTO at a single medical center from 2005 to 2009 were included. Internal fixation was used in all cases, with either a nonlocking (Puddu) or locking (Tomofix) plate. Patients were evaluated at 2, 6, and 12 weeks; 6 and 12 months; and annually thereafter. Types of potential surgical and postoperative adverse events, categorized into 3 classes of severity based on the subsequent treatments, were defined a priori. Medical records and radiographs were then reviewed by an independent observer. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were compared in subgroups of patients based on the categories of adverse events observed. Results: A total of 323 consecutive procedures (242 males) were evaluated (age, mean ± standard deviation, 46 ± 9 years; body mass index, mean ± standard deviation, 30 ± 5 kg/m2). Adverse events requiring no additional treatment (class 1) were undisplaced lateral cortical breaches (20%), displaced (>2 mm) lateral hinge fracture (6%), delayed wound healing (6%), undisplaced lateral tibial plateau fracture (3%), hematoma (3%), and increased tibial slope ≥10° (1%). Adverse events requiring additional or extended nonoperative management (class 2) were delayed union (12%), cellulitis (10%), limited hardware failure (1 broken screw; 4%), postoperative stiffness (1%), deep vein thrombosis (1%), and complex regional pain syndrome (CRPS) type 1 (1%). Adverse events requiring additional or revision surgery and/or long-term medical care (class 3) were aseptic nonunion (3%), deep infection (2%), CRPS type 2 (1%), and severe hardware failure with loss of correction (1%). Additional surgery rate was 3%. Class 1 and 2 adverse events did not affect patient-reported outcomes at 6, 12, or 24 months postoperatively. Patients with class 3 adverse events had significantly lower total WOMAC scores at 6 months but not at 12 or 24 months postoperatively. Conclusion: The most common adverse event in MOW HTO requiring extended nonoperative treatment (class 2) is delayed union (12%). The rate of severe adverse events requiring additional surgery and/or long-term medical care (class 3) is low (7%).

Treatment of Humeral Shaft Aseptic Nonunions in Elderly Patients With Opposite Structural Allograft, BMP-7, and Mesenchymal Stem Cells

Humeral shaft aseptic nonunions occur in 2% to 10% of patients managed conservatively and 10% to 15% of patients treated surgically. The complex muscular and neurovascular anatomy of the upper limb makes the surgical approach to the fracture site demanding and risky, especially when previous surgeries have been attempted. The clinical consequence of atrophic humeral shaft nonunions is a severe functional limitation that may significantly affect activities of daily living, especially in the elderly. The surgical treatment of humeral shaft nonunions is challenging for orthopedic surgeons. Patients with atrophic nonunions require both a stable fixation and enhancement of the biologic response because of the weak biologic reaction observed at the fracture site. The gold standard of treatment in elderly patients has not been described. Nonetheless, older age and comorbidities are associated with potentially malignant nonunions. This study reports the authors' experience using opposite cortical allograft combined with bone morphogenetic protein 7 and mesenchymal stem cells to treat humeral shaft atrophic nonunions in 2 elderly patients. The nonunion site healed at 4 months (patient 1) and 8 months (patient 2) postoperatively, with full return to activities of daily living and no pain. Neither patient reported complications of the radial nerve, which is at high risk of injury during this type of surgery. The only reported complication (patient 2) was an intraoperative longitudinal partial distal humeral fracture, probably caused by compression screw overtightening. The use of a locking plate and opposite cortical allograft, combined with BMP-7 and mesenchymal stem cells, represents a safe and effective treatment for malignant nonunions in older patients.