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Tibial Nonunion: Treatment Alternatives

University of Southern California School of Medicine, Los Angeles, and Southern California Orthopedic In-stitute, Van Nuys, Calif.

Because the spectrum of injuries to the tibia is so great, no single method of treatment is applicable to all nonunions. Therefore, it is important for surgeons who treat tibial nonunions to be skilled in several different methods of treatment. In patients with significant deformities, electrical stimulation, isolated fibular osteotomy, and bone grafts alone are unsatisfactory treatment options. In aseptic nonunions, the use of intramedullary nailing or compression plating appears to have many advantages. In previously closed and selected grade I and grade II open fractures, reamed intramedullary nailing is a safe and effective method of treatment. Because of the risk of infection, reamed nailing is not recommended after external fixation of open fractures. In these cases as well as others, the authors prefer plate osteosynthesis. With few exceptions, the plate should be placed, under tension, on the convex side of the tibia. Used in this fashion, the plate can assist in correction of any deformity and can also provide stable internal fixation. Half-pin external fixation is used primarily in the management of infected fractures. Ilizarov and other small-wire circular fixators have proved effective in treating complex-composite deformities associated with sepsis, bone loss, shortening, angulation, or malrotation. Amputation may be warranted if a functional limb cannot be achieved.