A 40-year-old female came to our clinic with the chief complaint of inability to flex her right elbow. Her elbow motion limitation was accompanied by pain. Six months prior to her first visit to our clinic, she was involved in a motorcycle accident. She was immediately brought to a rural hospital and was diagnosed with open fracture (Gustillo-Anderson grade IIIA) of the right distal third of humerus (AO12.C3). According to the operation report, the patient underwent debridement and external fixation. Afterward, she was discharged from the hospital. Unfortunately, due to economic condition, she was unable to comply for regular post-operative visits to the outpatient clinic for follow-up. Six months later, the patient was referred to our hospital because there is no sign of healing at the fracture site and the patient was unable to flex her elbow with pain.
At her first visit to our clinic, the examination revealed tenderness at the right distal third of the humerus with limited elbow flexion to only 30 . There was no sinus, pin tract infection or any sign of inflammation at the site of injury. The patient's expectation was to have her elbow pain-free and able to flex beyond 90 . A plain x-ray was made as shown in Fig. 1. From the x-ray, there was no sign of union or any bridging callus with some bone loss. No halo-sign was found in the pin or screw insertion sites.
The patient underwent surgery of removal of all of the implants from the bone followed by debridement of the nonunion site. The viability of the bone ends and the surrounding soft tissue was examined intraoperatively. It revealed that the nonunion site was actually well-vascularized as shown by adequate surface bleeding. After thorough debridement, removal of devitalized tissues, and freshening of nonunion sites, a bone defect of 5-centimeter long was found. The necessary components of tissue engineering to treat the bone defect were prepared. Freeze-dried cancellous bone allograft (Fig. 2a) and autologous platelet-rich plasma (PRP) (Fig. 2b) were processed and prepared before the operation by the Biomaterial Center and Tissue Bank of our hospital. The freeze-dried cancellous bone allograft had been processed according to the standard protocols of American Association of Tissue Bank (AATB), European Association of Tissue Bank (EATB), and Asia Pacific Association of Surgical Tissue Bank (APASTB). Ten-milliliter aspirated bone marrow was retrieved from the patient's iliac crest. The bone defect was filled with the combination of bone marrow aspirate, cancellous bone allograft, and PRP (Fig. 2c and d). To secure it from leaking away, fibrin glue was used to seal the filled defect (Fig. 2e). Lastly, internal fixation with plate and screws was done to achieve stability of the nonunion site. (Fig. 2f).
After the operation, the patient was regularly examined in the outpatient clinic to observe for any pain and sign of infection. The pain subsided as the healing progressed. There was no sinus or infection found at the surgical site. Radiographic images for three, six and twelve months were made to monitor callus formation (Fig. 3).
As the healing progressed, the x-ray showed the formation of bridging callus at the defect site. The bone graft was slowly resorbed and replaced by the formation of new bridging callus. Twelve months after surgery, the x-ray showed thicker bone formation (Fig. 3c). The patient was really satisfied because she could finally flex her right elbow beyond 90  to her expectation (Fig. 4).