Comparison of Functional and Cosmetic Outcomes According to Fracture Level in Gartland Type III Pediatric Supracondylar Humerus Fractures

Background@#Supracondylar humerus (SCH) fractures in children have been traditionally categorized according to the Wilkins-modified Gartland classification scheme, which is solely based on the degree of displacement. As this classification does not consider fracture patterns in the coronal or sagittal plane, the relationship between the fracture pattern and prognosis in SCH fractures remains unclear.Therefore, the purpose of this study was to evaluate the relationship between the fracture level and prognosis of pediatric SCH fractures. @*Methods@#Medical records and radiographs of 786 patients with SCH fractures who underwent surgical treatment between March 2004 and December 2017 were reviewed. A total of 192 patients were included in this study. Anteroposterior elbow radiographs taken at the time of injury were evaluated to obtain the level of fracture. Functional outcomes were evaluated based on modified Flynn grading at the last follow-up. @*Results@#Of 192 patients included in this study, 24 (12.1%), 148 (74.8%), and 20 (10.1%) had fractures in zone 1 (metaphyseal-diaphyseal area), zone 2 (between zones 1 and 3), and zone 3 (metaphyseal-epiphyseal area), respectively. There were significant differences in age at the time of injury (p = 0.011), direction of fracture displacement (p = 0.014), and loss of carrying angle (p < 0.001) between fractures in zone 3 and those in zone 1 or zone 2. Zone 3 fractures and classic zone 2 fractures also showed significant difference in outcomes, with zone 3 fractures having more unsatisfactory outcome than classic zone 2 fractures (p = 0.049). @*Conclusions@#For SCH fractures, varus deformity of the elbow was more common in zone 3 (metaphyseal-epiphyseal area) than in the other zones. Thus, pediatric orthopedic surgeons should be mindful of the possibility of cubitus varus deformity when treating SCH fractures in zone 3. A thorough postoperative follow-up is required.

Treatment Outcomes at Skeletal Maturity after Calcaneo-Cuboid-Cuneiform Osteotomy for Symptomatic Flatfoot Deformity in Children

Background@#The purpose of this study was to evaluate clinical and radiological outcomes at skeletal maturity after a calcaneo-cuboid-cuneiform osteotomy (triple C osteotomy) for symptomatic flatfoot deformity compared with healthy young adult controls. @*Methods@#Nineteen patients (30 feet) who undergone a triple C osteotomy for idiopathic symptomatic flatfeet from July 2006 to April 2013 were compared with 19 controls (38 feet). Radiographic measurements at preoperative examination, 1-year postoperative follow-up, and follow-up at skeletal maturity were evaluated. Functional outcomes were assessed by using the validated visual analog scale foot and ankle (VAS-FA) and the modified American Orthopaedic Foot and Ankle Surgery (AOFAS) score. @*Results@#In the triple C osteotomy group, 11 of 12 radiographic measurements were significantly improved at 1 year postoperatively and the last follow-up (p 0.05). There were no significant differences in nine of 12 radiographic measurements between the triple C osteotomy group at maturity and the control group (p > 0.05). Average VAS-FA and AOFAS scores were significantly improved at the time of skeletal maturity (p < 0.001). @*Conclusions@#Surgical correction of symptomatic flatfoot deformity in childhood resulted in favorable outcomes after the triple C osteotomy. Deformity correction was also maintained during follow-up at skeletal maturity.

Subungual Exostosis of the Little Finger: A Case Report and Review of the Literature in Korea / 대한피부과학회지

No abstract available.

Non-compartmental data analysis using SimBiology and MATLAB

MATLAB® is widely used for numerical analysis, modeling, and simulation. One of MATLAB's tools, SimBiology®, is often used for pharmacokinetic, pharmacodynamic model and dynamic systems; however, SimBiology seems to be rarely used for non-compartmental analysis (NCA), and the published official documentation provides a poor description of the analysis algorithm for NCA. Therefore, we conducted NCAs with a hypothetical dataset and some scenarios and compared the results. According to the results of this study, SimBiology estimates parameters using the unweighted linear regression for the terminal slope and linear interpolation method. Moreover, although the documentation describing the actual analysis algorithm used to process non-numeric data is not easily accessible to users, users may introduce numeric data at time zero to perform NCA properly. Using the command window, users can perform analyses more quickly and effectively. If the NCA official documentation were improved, SimBiology might be more widely adopted to perform NCA in clinical pharmacology.

Management of Flexible Flatfoot in Chidren and Adolescent / 대한정형외과학회잡지

Most children and adolescents with flexible flatfeet are asymptomatic and most do not require treatment. Scant convincing evidence exists to support the use of inserts or shoe modifications for effective relief of symptoms, and there is no evidence that those devices change the shape of the foot. Surgical correction is indicated for failure of prolonged nonsurgical attempts to relieve pain that interferes with normal activities and occurs under the medial midfoot and/or in the sinus tarsi. Osteotomies with supplemental soft-tissue procedures or arthroereisis are the suggested operative procedures for symptomatic flatfoot. An associated contracture of the heel cord is present in nearly all cases. Concurrent rigid forefoot supination deformity should be addressed as well.

Smad4 controls bone homeostasis through regulation of osteoblast/osteocyte viability

Regulation of osteoblast and osteocyte viability is essential for bone homeostasis. Smad4, a major transducer of bone morphogenetic protein and transforming growth factor-β signaling pathways, regulates apoptosis in various cell types through a mitochondrial pathway. However, it remains poorly understood whether Smad4 is necessary for the regulation of osteoblast and osteocyte viability. In this study, we analyzed Smad4Δ(Os) mice, in which Smad4 was subjected to tissue-specific disruption under the control of the 2.3-kb Col1a1 promoter, to understand the functional significance of Smad4 in regulating osteoblast/osteocyte viability during bone formation and remodeling. Smad4Δ(Os) mice showed a significant increase in osteoblast number and osteocyte density in the trabecular and cortical regions of the femur, whereas osteoclast activity was significantly decreased. The proliferation of osteoblasts/osteocytes did not alter, as shown by measuring 5′-bromo-2′deoxyuridine incorporation. By contrast, the percentage of TUNEL-positive cells decreased, together with a decrease in the Bax/Bcl-2 ratio and in the proteolytic cleavage of caspase 3, in Smad4Δ(Os) mice. Apoptosis in isolated calvaria cells from Smad4Δ(Os) mice decreased after differentiation, which was consistent with the results of the TUNEL assay and western blotting in Smad4Δ(Os) mice. Conversely, osteoblast cells overexpressing Smad4 showed increased apoptosis. In an apoptosis induction model of Smad4Δ(Os) mice, osteoblasts/osteocytes were more resistant to apoptosis than were control cells, and, consequently, bone remodeling was attenuated. These findings indicate that Smad4 has a significant role in regulating osteoblast/osteocyte viability and therefore controls bone homeostasis.

A Novel Simultaneous Determination of Sarpogrelate and its Active Metabolite (M-1) in Human Plasma, Using Liquid Chromatography-Tandem Mass Spectrometry: Clinical Application

BACKGROUND: This study describes a novel analytical method for simultaneously determining sarpogrelate and its metabolite (M-1) in human plasma, using liquid chromatography coupled with tandem mass spectrometry, with electrospray ionization in the positive ion mode. METHODS: Sarpogrelate, M-1, and labeled internal standard (d3-sarpogrelate) were extracted from 50 microL of human plasma by simple protein precipitation. Chromatographic separation was performed by using a linear gradient elution of a mobile phase involving water-formic acid (99.9:0.1, v/v) and acetonitrile-formic acid (99.9:0.1, v/v) over 4 min of run time on a column, with a core-shell-type stationary phase (Kinetex C18, 50 mm x 2.1 mm i.d., 2.6-microm particle size, Phenomenex, USA). Detection of the column effluent was performed by using a triple-quadruple mass spectrometer in the multiple-reaction monitoring mode. RESULTS: The developed method was validated in human plasma, with lower limits of quantification of 10 ng/mL for sarpogrelate and 2 ng/mL for M-1. The calibration curves of sarpogrelate and M-1 were linear over the concentration ranges of 10-2,000 and 2-400 ng/mL, respectively (R2>0.99). The carry-over effect, precision, accuracy, and stability of the method met the criteria for acceptance. CONCLUSIONS: A simple, fast, robust, and reliable analytical method was successfully developed and applied to the high-throughput determination of sarpogrelate and its metabolite in real plasma samples in a pharmacokinetic study of healthy subjects.

Patients with Persistent New-Onset Diabetes after Transplantation Have Greater Weight Gain after Kidney Transplantation

The purpose of the present study was to evaluate the difference in BMI pattern between patients with persistent new-onset diabetes after transplantation (P-NODAT) and without new-onset diabetes after transplantation (N-NODAT) in a retrospective matched case-control (1:3) analysis. Thirty-six patients who developed P-NODAT were identified among 186 adult renal transplant recipients with no evidence of pretransplant diabetes mellitus who underwent kidney transplantation from September 1997 to March 2008 and were treated with a triple regimen including tacrolimus. The controls were selected to match the patients for pretransplant BMI, age at transplantation (+/- 5 yr), and date of transplantation (+/- 12 months). Finally, 20 P-NODAT patients and 60 N-NODAT patients were selected. The pre- and posttransplant BMI data were collected every 16 weeks for up to 80 weeks. The clinical characteristics did not differ between the P-NODAT group and N-NODAT group. BMI increased faster in the P-NODAT group than in the N-NODAT group. The mixed-model analysis showed that patients with P-NODAT exhibited a faster increase in BMI. P-NODAT is associated with posttransplant weight gain. The risk of P-NODAT should be considered in patients with rapid weight gain after transplantation.

A Placebo-Controlled, Single and Multiple Dose Study to Investigate the Appropriate Parameters for Evaluation of Pharmacodynamic Equivalence of Voglibose in Healthy Korean Volunteers

BACKGROUND: Voglibose is an alpha-glucosidase inhibitor. The purpose of this study was to evaluate the pharmacodynamic characteristics of voglibose for determining the appropriate study design and parameters for a pharmacodynamic equivalence study of voglibose. METHODS: This study consisted of two studies. The single dose study had an open and single sequence design. Nineteen subjects received placebo and then one tablet of voglibose on two consecutive days with sucrose. The multiple dose study was performed with the similar design, except that it was a multiple dose of the single dose study. Nine subjects who showed an effective response in the single dose study received placebo three times and then voglibose 4 times on two consecutive days. Serial blood samples for pharmacodynamic parameters were taken until 180 mins after each administration. The baseline adjusted maximum serum glucose level (G(max)) and area under the serum glucose level-time profiles were determined and compared. RESULTS: In the single dose study, the difference in G(max) was -10.6 +/- 28.7 mg/dL. The area under the serum glucose concentration-time curve (AUGC(0-1h)) of placebo and voglibose were 7825.0 +/- 1145.3 mg.min/dL, 7907.5 +/- 917.2 mg.min/dL, respectively. In the multiple dose study, the difference in G(max) was 46.6 +/- 16.1 mg/dL. The AUGC(0-1h) of placebo and voglibose were 8138.6 +/- 721.9 mg.min/dL and 6499.7 +/- 447.2 mg.min/dL, respectively. The G(max) and AUGC(0-1h) of the multiple dose study was significantly different between placebo and voglibose in paired t-test. CONCLUSION: The differences in G(max) and AUGC(0-1h) are suitable for pharmacodynamic parameters to evaluate bioequivalence of voglibose.

Pharmacokinetic Characteristics of Cefcapene Pivoxil Hydrochloride after Single Oral Administration in Healthy Korean Subjects

BACKGROUND: Cefcapene pivoxil hydrochloride (CFPN-PI) is an oral ester cephalosporin antibiotic with a broad spectrum. In this study, we investigated the pharmacokinetics (PK) and tolerability of CFPN-PI following single oral administration in healthy Korean subjects. METHODS: An open label, dose escalation, parallel group study was conducted in 18 healthy male volunteers. A single dose of CFPN-PI was administered to 6 subjects in each treatment group of 100, 150 and 200 mg. Serial blood and urine samples were collected up to 12 h and 24 h after dosing, respectively. Plasma and urine concentrations of cefcapene were measured by HPLC-UV. PK parameters were estimated using non-compartmental analysis. For the safety evaluation, adverse event monitoring, clinical laboratory tests and physical examination were performed throughout the study. RESULTS: Median values of time to peak plasma concentration were observed around 1.5 to 2.0 h. Maximum plasma concentrations (Cmax) were 1.04 +/- 0.22, 1.24 +/- 0.46 and 1.56 +/- 0.43 mg/L (mean +/- SD), and area under the plasma concentration time curve (AUCinf) were 2.94 +/- 0.46, 3.97 +/- 1.28 and 4.70 +/- 1.19 h*mg/L in 100, 150 and 200 mg dose groups, respectively. The differences of dose normalized Cmax and AUCinf among three groups were not statistically significant. The fractions of drug excreted in urine unchanged were 31.5 % - 42.9 %. There were no serious adverse events or clinically significant abnormalities related to CFPN-PI. CONCLUSION: CFPN-PI was well tolerated with single oral administration and showed a linear PK property within 100 - 200 mg in healthy Korean male subjects.

Pharmacokinetics of T-614 after Single Oral Administration in Healthy Korean Volunteers

BACKGROUND: Iguratimod is a new type of disease modifying anti-rheumatic drug, which reduced the production of inflammatory cytokines. The purpose of this study was to evaluate pharmacokinetic characteristics and safety profiles of iguratimod after a single oral administration in healthy Korean volunteers. METHODS: A randomized, double-blind, placebo-controlled, parallel group, single oral dose study was conducted in 24 healthy male volunteers. Three groups of eight subjects each received 25 mg, 50 mg, or 100 mg dosage, respectively. Two subjects in each dose group were administered matching placebo. Plasma concentrations of iguratimod were measured till 72 hours after drug administration. Tolerability was evaluated by monitoring adverse events, clinical laboratory tests, and 12-lead electrocardiograms. RESULTS: The mean area under the concentration-time curve from 0 to 72 hours (AUClast) were 11.9, 25.2, and 51.8 mg x h/L and the maximum plasma concentration (Cmax) were 1.15, 2.33, and 4.78 mg/L in 25, 50 and 100 mg dose groups, respectively. All doses of iguratimod were well tolerated without serious adverse events or clinically meaningful changes. CONCLUSION: Cmax and AUClast values of iguratimod proportionally increased with incremental dose. Iguratimod was generally safe and well tolerated.

Outcomes of Treatment for Squamous Cell Carcinoma Originating as a Marjolin's Ulcer / 대한골관절종양학회지

PURPOSE: The purpose of this study was to analyze the results of treatment and prognosis of Marjolin's ulcer compared with primary squamous cell carcinoma. MATERIALS AND METHODS: Fourteen patients treated for Marjolin's ulcer were analyzed. Twenty patients with primary squamous cell carcinoma treated during the same time period was the control group. Mean age was 61.2 years. There were 24 males and 10 females. The locations, TNM stages, histological grades, recurrence, metastasis, and survival rate were analyzed and compared between two groups. RESULTS: The mean follow-up period was 54.8 months (range, 12-168 months). Local recurrences were found in 6 cases, 5 ones in Marjolin's ulcer patients, and one case in primary squamous cell carcinoma patients. The mean time interval between the initial presentation and occurrence of local recurrences was 9 months (range, 2-20 months). There were 6 metastases. 2 (14.3%) metastases were found in Marjolin's ulcer patients, and 4 (20.0%) metastases in primary squamous cell carcinoma patients. Total events (metastasis or local recurrence) were found in 10 pateients, 6 of them in Marjolin's ulcer group, and the remaining four in primary group. 5-year disease-free survival rate was 64.3% in Marjolin's ulcer group and 95.0% in primary squamous cell carcinoma group. CONCLUSION: Squamous cell carcinomas originating as Marjolin's ulcers revealed higher recurrence rate and lower survival rate despite of aggressive treatment. Therefore, new treatment modalities should be developed for improving outcomes.

Over-expression of PTEN Involved in Troglitazone-induced Apoptosis in Human Osteosarcoma Cells / 대한골관절종양학회지

PURPOSE: We investigated the effects of phosphatase and tensin homologue deleted on chromosome 10 gene phosphatase and tensin homologue deleted on chromosome 10 gene (PTEN) expression on the cell proliferation and on the responsiveness of troglitazone in osteosarcoma cells. MATERIALS AND METHODS: Western blotting alnalysis was performed to detect the expression of PTEN in U-2OS cells treated with troglitazone. WST (water-soluble tetrazolium) assay was used to evaluate cell proliferation. Flow cytometry was used to determine cell apoptosis. Further, transfection of wild-type PTEN plasmid DNA was used to upregulate PTEN expression. RESULTS: Troglitazone treatment induced growth inhibition of U2-OS cells in a dose- and time-dependent manner. Troglitazone increased the expression of PTEN in a dose-dependent manner. PTEN upregulation induced by troglitazone treatment resulted in cell growth inhibition and apoptosis in U-2OS cells. PTEN over-expression by plasmid transfection enhanced these effects of troglitazone. Moreover, no changes were observed in the mutant type-PTEN group. CONCLUSION: Upregulation of PTEN is involved in the inhibition of cell growth and induction of cell apoptosis by troglitazone. Further, PTEN over-expression can cause cell growth inhibition in osteosarcoma cells and these cell growth inhibitions could be enhance by troglitazone treatment.

Analysis of Influencing Factors to Depth of Epidural Space for Lumbar Transforaminal Epidural Block in Korean

BACKGROUND: Transforaminal epidural steroid injection is one of the effective treatments in managing radicular pain. There have been some prospective studies on the depth to the epidural space with the transforaminal approach. However, there have been no studies about the depth in Asians, especially Koreans. This study was carried out in order to evaluate the depth to the epidural space and the oblique angle and factors that influence the depth to the epidural space during lumbar transforaminal epidural injection. METHODS: A total of 248 patients undergoing fluoroscopically guided transforaminal epidural steroid injections were evaluated. At the L3-4, L4-5, L5-S1, and S1 levels, we measured the oblique angle and depth to the epidural space. RESULTS: Needle depth was positively associated with body mass index (correlation coefficient 0.52, P = 0.004). The median depths (in centimeters) to the epidural space were 6.13 cm, 6.42 cm, and 7.13 cm for 50-60 kg, 60-70 kg, and 70-80 kg groups, respectively, at L5-S1. Age and height were not significantly associated with the needle depth. CONCLUSIONS: There is a positive association between the BMI (and weight) and transforaminal epidural depth but not with age, sex, and height.

First Metatarsal Dorsal Close Wedge Osteotomy Combined with Medial Cuneiform Plantar Open Wedge Osteotomy for the Treatment of a Cavus Foot / 대한정형외과학회잡지

PURPOSE: We wanted to analyze the results of the 1st metatarsal dorsal close wedge osteotomy (MTDW) combined with medical cuneiform plantar open wedge (MCPOW) for treating forefoot deformity of a cavus foot. MATERIALS AND METHODS: We retrospectively analyzed 30 patients. Their mean age was 21.5 years (SD 10.6 years) and the average follow-up period was 2.3 years. Thirty-four cases of thirty patients were classified as group A, as classified by the 1st MTDW combined with the MCPOW, 16 feet (14 patients) were group B by the 1st MTDW or MCPOW, 12 feet (10 patients), and group C by triple arthrodesis, 6 feet (6 patients). We evaluated the ankle dorsiflexion, plantarflexion, heel alignment, and the Maryland foot score (MFS) preoperatively and the last follow-up, and we analyzed the radiologic Hibb, Meary, calcaneal pitch and tibiotalar angles. RESULTS: The ankle dorsiflexion (p=0.01), plantar flexion (p=0.03) and heel alignment (p=0.02) of group A were significantly improved more than that of groups B and C. The MFS of group A revealed better than group B and C (p=0.01). The Meary (p=0.01), Hibb (p=0.02) and calcaneal pitch angle (p=0.02) of group A were significantly improved more than that of groups B and C. CONCLUSION: 1st MTDW combined with MCPOW osteotomy that focuses at the apex of the deformity for correction of a cavus foot can obtain better clinical and radiological results than other surgical procedures.

Treatment Outcomes of Triplane and Tillaux Fractures of the Ankle in Adolescence

BACKGROUND: To identify the fracture configuration and treatment results for patients with triplane and Tillaux fractures in the ankle joint. METHODS: A retrospective study was performed on 14 patients with a more than one year follow-up. This study investigated the fracture configuration, concomitant fibula fracture, treatment methods and complications. The treatment outcomes were analyzed using modified Weber protocol. RESULTS: Among the 14 cases, 11 were triplane fractures and 3 were Tillaux fractures. Seven were two part triplane fractures, and 4 were three part triplane fractures. Eight were lateral triplane fractures, and 3 were medial triplane fractures. A fibula fracture was accompanied by 7. The fibular fracture comprised of oblique fractures in all cases. A closed and open reduction was performed in 6 and 8 cases, respectively. All but one showed excellent treatment outcomes at the final follow-up. Traumatic arthritis developed in 1 case. CONCLUSIONS: Precisely detecting the fracture configuration by computed tomography and understanding the injury mechanism have greatly improved the outcomes of triplane fractures and Tillaux fractures of the ankle in adolescent patients.

Analysis of the Recurrence after Surgical Treatment of the Hemangioma in the Extremities / 대한골관절종양학회지

PURPOSE: To analyse the risk factors for recurrence of hemangiomas in extremities after surgical treatment and to compare with those of trunk. MATERIALS AND METHODS: 120 cases of hemangioma with surgical treatments from June 1998 to September 2009 were analysed. 53 cases with surgical treatment on trunk in the same period were set to be the control group. We analyze several factors: age, location, site, size, histologic types and correlation between recurrence and each risk factor using logistic regression analysis. RESULTS: Recurrence rate was 11.7% in extremities and 9.4% in trunk. There were no correlation between recurrence and age, site, size, histologic type. But, there was stastically significant correlation between recurrence rate and location, especially hand, forearm, feet in extremities and head and neck in trunk. CONCLUSION: Recurrence after surgical treatment of hemangioma is highly prevalent in anatomical location such as, hand, foot and forearm those are difficult to achieve complete resection because of close to neurovascular structures. Careful observation should be needed owing to incomplete resection can occurs recurrence.

Analysis of Treatment Outcomes for Open Fractures of the Tibia in Children / 대한정형외과학회잡지

PURPOSE: Our objective was to analyze outcomes of treatment for open fractures of the tibia in children according to the classification of Gustilo-Anderson type. MATERIALS AND METHODS: We reviewed thirty five pediatric patients who underwent surgery for open fractures of the tibia between June 1998 and June 2007. We followed up over more than 1 year. Fractures were grouped into three types according to Gustilo-Anderson classification (Types I, II, and III). External fixation or flexible intramedullary nailing was used as the surgical method. We analyzed the period required to achieve radiologic bony union, tibial alignment, leg length discrepancy and complications. Clinical outcomes were assessed using the Karlstrom-Olerud method. RESULTS: Radiologically, bony union was achieved in 11.35+/-3.08 weeks, 10.50+/-2.20 weeks, and 21.62+/-7.19 weeks for types I, II, and III, respectively. Delayed union occurred in one case of type II and 3 cases of type III fractures. Complications such as nonunion, malunion and osteomyelitis were seen only in type III. Clinical outcomes showed excellent or good results in all cases except one (type III). CONCLUSION: Excellent outcomes for open fractures of the tibia in children can be obtained regardless of Gustilo-Anderson type when adequate procedures are performed.

Air Bubbles Mimic Disc Herniation in MRI after Cervical Epidural Block

Magnetic resonance image (MRI) is the most sensitive imaging test of the spine in routine clinical practice. Unlike conventional x-ray examinations and computed tomography scans, high-quality magnetic resonance images can be assured only if patients are able to remain perfectly still. However, some patients find it uncomfortable to remain still because of pain. In that condition, interlaminar cervical epidural injections can reduce pain and allow the procedure. When using air with the "loss of resistance" technique in epidural injections to identify the epidural space, there is the possibility of injected excessive air epidurally to mimic a herniated disc. We describe a case report of epidural air artifact in a cervical MRI after cervical epidural injections.

Comparison of Treatment Outcomes of Infected Nonunion of the Tibia by Ilizarov Fixator according to Location of Nonunion and Reconstruction of Soft Tissue Defect

PURPOSE: To study clinical results and complications in the treatment of infected nonunion of the tibia according to location of nonunion and reconstruction for soft tissue defect. MATERIALS AND METHODS: 36 cases of tibia infected nonunion which were treated with the llizarov included in this study. There were proximal 1/3 in 14, middle 1/3 in 10, and distal 1/3 in 11 cases. Coverage of the soft tissue were treated with the free flap in 8 cases as classified group A and non-free flap in 17 cases classified group B. We evaluated the healing index, complications and comparing the results of each treatment by the Paley method. RESULTS: Bone union was achieved in all cases. The proximal nonunion showed better results than those in the middle and distal area; average healing index: 35.6 days/cm (p=0.038), bone results: 92.9% (p=0.025), functional result: 90.5% (p=0.03). Group B showed significantly better results as it showed average healing index: 30.3 days/cm (p=0.015), bone results: 85.7% (p=0.025), functional results: 90.5% (p=0.015). CONCLUSION: The nonunion of proximal 1/3 showed better results than other sites. Soft tissue reconstruction with free flap that control infection more effectively, could be improved the treatment outcomes.