PMC6503138_01
An x-ray made when the patient came to our hospital for the first time. The patient underwent debridement and external fixation in the previous hospital (source: internal documentation).
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Fig. 1. From the x-ray, there was no sign of union or any bridging callus with some bone loss.
(a) Freeze-dried cancellous bone allograft produced by our tissue bank; (b) PRP; (c) the mixture of cancellous bone allograft, PRP and aspirated bone marrow; (d) application of the mixture to the defect site; (e) Sealing with fibrin glue; (f) Postoperative x-ray (source: internal documentation).
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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 (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).
Radiological follow-up for (a) 3 months, (b) six months, and (c) 12 months (source: internal documentation).
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Radiographic images for three, six and twelve months were made to monitor callus formation (Fig. 3). Twelve months after surgery, the x-ray showed thicker bone formation (Fig. 3c).
Evaluation after 12 months showed that the patient could flex her right elbow to 145  (source: internal documentation).
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The patient was really satisfied because she could finally flex her right elbow beyond 90  to her expectation (Fig. 4).
PMC6503138_02
(a) Initial x-ray after the accident, (b) x-ray was taken in the first visit to our hospital with the cast removed (source: internal documentation).
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Eight months prior to her visit to our hospital, she fell from a coconut tree and had an open fracture (Gustilo-Anderson grade IIIB) of the left tibia (AO42.C3) (Fig. 5a). An x-ray was done, and it showed that there was nonunion of the left tibia with union of the fibula (Fig. 5b).
(a) Post-operative x-ray, (b) two months after surgery, (c) four months after surgery, (d) the patient was pain-free and able to walk.
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Compared to the x-ray taken right after the surgery (Fig. 6a), the x-ray was taken two and four months after the surgery (Fig. 6b and c) showed the formation of the bridging callus. Clinically, the patient was pain-free and was able to walk without assistance (Fig. 6d).