An infected nonunion of the distal tibia after plating is uncommon, and the traditional methods for its treatment have unique disadvantages (time-consuming and patient discomfort being great). A single-stage surgical technique was developed to improve the outcome in this situation. Retrospective. University hospital. We treated 25 consecutive adult patients with 25 infected nonunions of the distal tibia after plating. The inclusion criteria consisted of infected nonunions of the distal tibia with an intact ankle space and a plate in situ. The surgical technique used with all participants called for the removal of all implants, intra-/extramedullary débridement, and placement of cancellous bone graft and antibiotics (vancomycin and gentamicin) followed by the application of an Ilizarov external fixator. Postoperatively, patients ambulated early with protected weightbearing and performed range-of-motion exercises of the ankle. Twenty-two patients were followed up for at least 2 years (range, 2.0-4.5 years; median, 3.2 years). All infected nonunions healed without recurrence of infection. The median time to union was 4.5 months (range, 3.5-6.0 months). Eighteen cultures had single bacterial flora, whereas five cultures had mixed flora. Two cultures showed no growth of microorganisms. All bacteria were sensitive to vancomycin or gentamicin. Methicillin-resistant Staphylococcus aureus (13 of 25) and methicillin-sensitive S. aureus (seven of 25) were the most commonly detected microorganisms. Patients' ankle function improved with "satisfactory" grades increasing from 0% preoperatively to 86% postoperatively (P < 0.001). This single-stage surgical technique had a high success rate with significant reduction in patient discomfort during the course of treatment. However, further revision of the technique may be necessary to ensure high success rates in further series.

The aim of this study was to compare the superiority between the newly designed modified AO tension band wiring technique and the traditional modified AO tension band wiring technique in treating an olecranon fracture. Eight pairs of fresh cadaveric ulnae were tested biomechanically. After transverse osteotomy of the olecranon, all left ulnae were fixed by the traditional modified AO technique with two Kirschner wires inserted through the anterior ulnar cortex and all right ulnae by the new technique with two Kirschner wires inserted into the marrow cavity from the olecranon to the ulnar styloid process. All specimens were tested by the Material Testing System machine to evaluate fragment displacement and the maximal failure load. A dual linear variable displacement transducer was used to measure relative minimal displacement. There was no significant difference between the techniques. The maximal failure load by either technique was more than 80 kg. Even at testing failure, no Kirschner wires migrated proximally. The new technique may be applied widely to treat all olecranon fractures, because it is a technically easier and safer technique. Less than 5.5-kg loads could be permitted in daily activity postoperatively. A single tolerable loading weight should not exceed 8 kg. Kirschner wires will not migrate proximally, despite increased joint loading. Clinically, this study may confirm indirectly the hypothesis that proximal migration of Kirschner wires was mainly due to triceps traction.

Exchange nailing has been the favored method to treat aseptic nonunions of the femoral shaft. The recommended amount of over-reaming is at least 2 mm. The purpose of this study was to determine whether the effectiveness of nonunion treatment is greatly reduced with less than 2 mm of over-reaming. Aseptic nonunions of the femoral shaft were treated by exchange nailing with 1 mm (n = 37) or at least 2 mm (n = 44) of over-reaming. Union rates, union periods, and complications were compared. Indications for exchange nailing were aseptic nonunions of the femoral shaft with an inserted intramedullary nail, shortening of less than 1.5 cm, and a fracture gap of less than 5 mm. After a mean follow-up of 3.6 years (range, 1.1–7.1 years), union rates were 31 (91.2%) of 34 nonunions with over-reaming of 1 mm and 37 (92.5%) of 40 nonunions with over-reaming of 2 mm or more (p = 0.32). The mean union periods were 4.4 months (range, 2.5–8 months) and 4.4 months (range, 3–8 months), respectively (p = 0.83). Except for persistent nonunions, no significant complications occurred. Exchange nailing can be considered the first choice to treat aseptic nonunions of the femoral shaft. The diameter of the new intramedullary nail should be as large as possible to reinforce the mechanical strength of the repair. The osteogenic potential stimulated by the reaming of cancellous bone graft was similar with over-reaming of 1 mm and with over-reaming of 2 mm or more.