Tibial Nonunion: Treatment Alternatives

Donald A. Wiss, MD, and William B. Stetson, MD

Abstract
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.
J Am Acad Orthop Surg 1996;4:249-257

Nonunion of the tibia after highenergy trauma continues to be a common problem. Treatment is influenced by the location of the
nonunion, the integrity of the soft tissues, the presence or absence of infection, the angular and rotational alignment of the limb, the degree of
instability at the nonunion site, and
the radiographic appearance. If rational treatment is to be instituted, the
surgeon must have a clear understanding of the personality of the
nonunion, since no single method of
treatment is applicable in all situations. The approach to treatment
may be nonoperative or surgical and
can be broadly viewed as functional,
electrical, mechanical, biological, or
some combination thereof. Results

Vol 4, No 5, September/October 1996

are optimized when deformities are

corrected and adequate stabilization
of the fracture allows early range-ofmotion and weight-bearing activities.
Despite the availability of improved surgical techniques, more potent antibiotics, and sophisticated
soft-tissue coverage procedures,
nonunion still occurs in many patients after high-energy tibial fractures. Recent advances in soft-tissue
reconstruction with the use of muscle
flaps or free-tissue transfer have been
effective in decreasing the rate of infection after many severe injuries.1
Unfortunately, the addition of vascularized soft tissue alone has a less dramatic effect on the promotion of fracture healing in complex-composite
injuries. Failure to achieve union in a

timely fashion is often associated

with prolonged morbidity, inability
to return to work, the need for multiple operative procedures, and emotional impairment. In virtually all
cases of tibial nonunion, loss of limb
function is common, with varying degrees of muscle atrophy, compromise
of the soft tissues, osteopenia, and
decreased range of motion of the
knee, ankle, or subtalar joints.
The problems facing the orthopaedic surgeon are challenging.
Treatment must be designed to correct axial or rotational malalignment, equalize leg lengths, prevent
or treat established infection, and allow functional restoration of the
limb. Finally, the surgeon must
choose among many diverse treatment modalities, all of which, when
correctly done, have high rates of
success. These include cast or brace
immobilization, electrical stimulation, fibular osteotomy, bone grafting, internal fixation with plates or
intramedullary nails, and external

Dr. Wiss is Clinical Professor of Orthopedic

Surgery, University of Southern California
School of Medicine, Los Angeles, and is in private
practice with Southern California Orthopedic Institute, Van Nuys, Calif. Dr. Stetson is Attending Surgeon and Sports Medicine Director, Missouri Bone and Joint Center, St. Louis.
Reprint requests: Dr. Wiss, Southern California
Orthopedic Institute, 6815 Noble Avenue, Van
Nuys, CA 91405.
Copyright 1996 by the American Academy of
Orthopaedic Surgeons.

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Tibial Nonunion
fixation with either small-wire or
conventional devices.

Etiology
Although there have been a large
number of clinical studies, the definition of tibial nonunion remains arbitrary. Traditionally, a finite period of
time was allowed to elapse before a
fracture was defined as being characterized by delayed union or nonunion.
If fracture stability or bridging callus
was not present between 16 and 20
weeks, the fracture was described as
delayed union. The term nonunion was usually reserved for those
fractures that had not healed after 9
months of adequate treatment. This
passive approach undoubtedly prolonged morbidity in many patients
with tibial fractures.
In the past two decades, orthopaedic surgeons have become increasingly aware that many highenergy tibial fractures are slow to
consolidate despite adequate initial
treatment. Rather than being limited by a definition of nonunion that
involves a set time frame, they have
come to realize that earlier and more
aggressive treatment is warranted.
Several authors have shown that
surgical intervention is usually indicated 3 to 5 months after injury if the
fracture fails to show progressive
signs of healing on monthly radiographs. 2-4 In this environment, a
nonunion or at least delayed union
can be predicted, and a change in
treatment is justified. Therefore, the
designation of a delayed union or
nonunion is currently made when
the surgeon believes that the fracture has little or no potential for
union and additional treatment is
needed.
Although the etiology of tibial
nonunion is diverse, the vast majority
of these injuries fail to unite because
the initial fracture displacement has
damaged the surrounding soft tis-

250

sues, leading to profound changes in

the medullary and periosteal blood
supply. Union is further delayed if
the fracture becomes infected. Other
factors that have been implicated in
the etiology of nonunion include fracture comminution, segmental fracture patterns, bone loss, distraction,
inadequate immobilization, the presence of an intact fibula, inadequate
fixation, and delayed weight bearing.
Smokers have also been shown to
have significantly longer mean times
to clinical union and a higher incidence of delayed union compared
with nonsmokers.

Classification
Two important factors in the classification of nonunions are the expected
vascularity at the fracture site and the
presence or absence of infection. One
method of classifying nonunions is to
indirectly assess the vascularity at the
fracture site on radiographs or radionuclide scans. With a hypertrophic nonunion, there has been an
obvious attempt at bone healing, with
the production of callus leading to
flared, often dense bone ends. As a
general rule, hypertrophic nonunions
are well vascularized. In contrast, in
an atrophic nonunion, there has been
little or no effort to heal. Callus is
scanty or absent, the bone ends are tapered and osteopenic, and bone vascularity may be deficient. Nonunions
characterized by bone loss or congenital pseudarthrosis are unique types
that do not fit well into a classification
based on vascularity alone.
Nonunion can also be classified
on the basis of infection. The fracture may be noninfected, previously
infected, or currently infected.

Rationale for Treatment

The treatment of a tibial nonunion is
influenced by its location, the in-

tegrity of the soft tissues, the presence or absence of infection, the angular and rotational alignment of
the limb, the degree of instability at
the nonunion site, and the radiographic appearance. If rational
treatment is to be instituted, the surgeon must have a clear understanding of the individual characteristics
of the nonunion, since no single
method of treatment is optimal in all
cases. The patients nutritional status, weight, associated medical
problems, smoking history, neurovascular status, and soft-tissue envelope must be carefully assessed.
After a detailed examination of the
extremity and a careful review of
imaging studies, the surgeon must
choose the method of treatment that
appears most likely to lead to fracture union. The approach to treatment may be nonoperative or surgical, and the options can be broadly
viewed as functional, electrical, mechanical, biological, or some combination thereof. It is the surgeons
role to identify the proper stimulus that will lead to uneventful
fracture healing.
For example, in the case of patients with hypertrophic tibial
nonunions, several authors have
shown that the failure to unite is
primarily a mechanical problem. In
this environment, the proper stimulus is stable fixation of the fracture, which reduces micromotion at
the nonunion site, allowing capillary ingrowth with endochondral
ossification. The addition of a biological stimulus in the form of a
bone graft is not necessary or indicated. If the fracture fragments are
well aligned, it is not necessary to
take down the nonunion because
the mesenchymal tissue between
the bone ends retains the capacity
to form osseous tissue in the proper
environment. However, atrophic
nonunions, with their restricted
blood supply, require the additional stimulation provided by

Journal of the American Academy of Orthopaedic Surgeons

Donald A. Wiss, MD, and William B. Stetson, MD

shingling or augmentation at the

fracture site with bone graft.

Diagnostic Workup
When evaluating a patient with a
tibial nonunion, it is essential to
carefully review pertinent prior
medical records and imaging studies
before initiating additional treatment. The vast majority of patients
with a long and complicated history
of tibial nonunion are unable to provide accurate information about
such factors as previous open
wounds, degrees of contamination,
culture reports, and antibiotic sensitivities. Unlike acute injuries, tibial
nonunions rarely require immediate
intervention. The urge to operate
should be tempered by the knowledge that these injuries can be extremely challenging and fraught
with the potential for multiple complications.
An anteroposterior and a lateral
radiograph will generally allow adequate assessment of the nonunion
site. However, in some cases, the
obliquity of the nonunion may be
out of plane on these two views,
giving the false impression of adequate healing. If the fracture morphology is not clear or there is persistent pain at the fracture site,
40-degree internal- and external-rotation oblique views may be very informative. Occasionally, examination of the limb under fluoroscopy,
with or without stress views, may
help to identify subtle motion at the
fracture site. Linear tomography can
also be useful in the evaluation of
fracture healing, particularly in the
presence of fixation hardware. In
the absence of fixation devices, computed tomography and magnetic
resonance imaging have supplanted
linear tomography in the assessment
of fracture healing.
The role of radionuclide scanning
in the assessment of delayed union

Vol 4, No 5, September/October 1996

and nonunion remains poorly defined. It has been used primarily to

investigate the possibility of infection. Subclinical, undetected infection remains a significant therapeutic problem in the management of
tibial nonunions.5 Knowledge of the
presence or absence of infection is of
vital importance to the surgeon
weighing multiple treatment alternatives. Except in moderate to advanced cases, plain radiographs
usually do not reveal signs of osteomyelitis at the nonunion site. Although the localized uptake of technetium-99m diphosphonate reflects
a reparative bone process, it is not
specific for infection. Gallium-67 citrate accumulates at the site of inflammation, but it too is not specific
for active infection. Even with sequential technetium or gallium
scintigraphy, most studies report accuracy rates of only 50% to 60% in
defining subclinical osteomyelitis.
Indium-111labeled leukocyte scans
have been shown to have high sensitivity, specificity, and accuracy in
acute osteomyelitis, but they are
much less effective in the diagnosis
of chronic, subacute, and indolent
bone infections.6-9
Magnetic resonance imaging can
be useful in the diagnosis of acute
and chronic bone and soft-tissue infections.10-13 The multiplanar imaging capability and the high degree of
contrast resolution allows accurate
delineation of the limits of an infective process. It can be used to locate
a small sequestrum in a patient with
chronic drainage or to evaluate the
quality of the interface with an avascular wedge or butterfly fragment.
A study is considered to be consistent with osteomyelitis when an area
of abnormal marrow showing increased signal intensity on T2weighted images corresponds with
an area of low signal on T1-weighted
sequences. Sinus tracts can be followed as high-signal-intensity fluid
areas on T2-weighted images that

extend through the skin and subcutaneous tissues into defects in the
bone and marrow.
Magnetic resonance imaging can
also play a vital role in the assessment and planning of the surgical
treatment of patients with acute or
chronic osteomyelitis complicating
fracture healing, because it can be
used to define the intramedullary
extent of the infection before surgical debridement. In one study, 13
bone infection was identified with a
diagnostic sensitivity of 100%, a
specificity of 63%, and an accuracy
of 93%.
Tissue biopsy remains a useful
technique for evaluating infection
complicating fracture repair.14 Antibiotic therapy should be discontinued for at least 72 hours before
biopsy, and several representative
biopsy specimens should be obtained for analysis. Cultures should
be sent for aerobic, anaerobic, fungal, and acid-fast studies as indicated. Gristina et al14 have reported
that even open biopsy techniques
may yield information that is less
than complete because of the problem of analyzing bacteria protected
by external glycocalyx.

Nonsurgical Treatment
Functional Casts or Braces
In a small number of cases, continued nonoperative treatment of a tibial nonunion may be appropriate.
Occasionally, a fracture treated in a
non-weight-bearing long-leg cast will
heal after conversion to a weightbearing cast or brace. The introduction of weight bearing provides a
functional stimulus that alters the
fracture environment, leading to callus formation and fracture consolidation.15 The stimulus of weight bearing and intermittent loading can be
sufficient to induce healing in a fracture not subjected previously to loading. This method of treatment allows

251

Tibial Nonunion
mobilization of the knee, ankle, and
subtalar joints. Fracture bracing improves muscle and skin quality and
rarely is a bridge-burning procedure. Although disability may be extended, the costs are minimal, and the
risks appear relatively low. If the
fracture fails to unite, alternative
methods of treatment are possible
with little additional risk.

Surgical Treatment

based on the belief that the fibula

acts as a distraction strut, preventing
compressive forces on the tibial fracture site. When both the tibia and
the fibula are fractured, the fibula almost always heals first, sometimes
in as little as 6 to 8 weeks. Once
healed, it may become load sharing
and thus decrease actual loads
across the tibial fracture site. When
the fibula is not fractured, it may
prevent close apposition of the tibial
fragments and protect the tibia from
its full axial load.
Fibular osteotomy is more commonly used as an adjunctive procedure to assist with deformity correction when combined with surgical
stabilization of the tibia. The indications for isolated fibular osteotomy
should be confined to stable hypertrophic nonunions with little or no
deformity. The advantages of osteotomy of the fibula are its low morbidity and cost and the fact that it
rarely precludes subsequent procedures.
Most investigators favor resection of a 1.5- to 2.5-cm segment of the
fibula. Resection of larger amounts
increases morbidity, provides no additional compressive force on the
tibia, and may increase tibial fracture instability or jeopardize a posterolateral bone graft if the tibial
fracture fails to unite. Additional
disadvantages of isolated fibular osteotomy include a mixed record of
success, the inability to overcome
substantial degrees of deformity,
and the necessity of additional prolonged casting or bracing of the tibial nonunion. Contraindications to
the procedure include unstable atrophic nonunions, synovial pseudarthrosis, active infection at the tibial
fracture site, unacceptable tibial angulation, and the inability of the patient to bear weight.

Fibular Osteotomy
Osteotomy of the fibula in an attempt to encourage tibial union is

Bone Grafts
Autogenous bone transplantation, usually involving grafts from

Electrical Stimulation
The use of electrical stimulation in
the management of delayed union
and nonunion continues to be controversial. To date, the exact mechanism
of bone healing by electrical stimulation is not completely understood.
While there is a large volume of literature advocating its use, there are few
prospective, double-blind, randomized studies.16,17 The technique is best
indicated in a compliant patient with
a stable hypertrophic nonunion with
little or no clinical deformity.
The technique requires excellent
patient compliance, is expensive,
and generally requires immobilization. The major drawback is the inability to address the associated
problems of angulation, malrotation, and limb shortening that often
occur in patients with tibial nonunions. Furthermore, lack of compliance by many patients also limits
its use. In our experience, electrical
stimulation has often been recommended for patients with unstable,
mobile, atrophic nonunions, in
whom the technique has little or no
chance of success. Although they
are doubtless well intentioned, surgeons may prolong patient morbidity and increase costs attempting to
avoid the more risky but successful
approach of surgical management.

252

the iliac crest, remains the classic

method of treatment of tibial
nonunions in a variety of locations
(Fig. 1). The most common use of
bone grafts is as a biological stimulus in the management of atrophic
tibial nonunions. The use of large
cortical struts (either autograft or allograft), with their low surface-area
vascularity and low porosity, requires more time for vascular ingrowth before incorporation and is
not recommended.
Anterolateral grafting of the tibia
has been used extensively in the
past, but the proximity to traumatic
anterior wounds increases the rate of
wound complications. Furthermore, the amount of bone graft that
can be inserted is relatively small.
The posterolateral approach is the
preferred technique in the middle
and distal thirds of the bone.18 When
the fracture site is exposed, care
must be taken not to disturb the fibrous union or penetrate the interosseous membrane. The fibrous tissue helps stabilize the fracture
fragments, has osteogenic potential,
and may contribute to consolidation
of the fracture. The posterolateral
approach avoids open wounds,
scars, and draining sinuses, which
are often present in the anterior or
anteromedial aspect of the leg when
there has been extensive soft-tissue
damage. The anterior compartment
is not violated when the posterolateral approach to the tibia is employed. In the proximal third of the
tibia, proximity to the neurovascular
structures makes posterolateral
grafting risky. In these cases, a posteromedial graft may be preferable.
Connolly et al19 popularized the
use of percutaneous bone marrow
injections to treat delayed unions
and nonunions of the tibia. These
authors as well as others 20 have
shown, both in vitro and in vivo, that
healing of nonunions can be successfully stimulated by injecting autologous marrow into defects. The

Journal of the American Academy of Orthopaedic Surgeons

Donald A. Wiss, MD, and William B. Stetson, MD

Fig. 1 A, Bone loss associated with a grade IIIB fracture of the tibia in association with a segmental fibular fracture affecting ankle stability.
After irrigation and debridement, the tibia was stabilized with half-pin external fixation, and a plate was applied to the distal fibula. B, Five
days after injury, the soft tissues were reconstructed with a rectus abdominis free-tissue transfer. At 6 weeks, the flap was elevated, and an
iliac-crest bone graft was placed anteriorly into the tibial defect. C, At follow-up at 18 months, complete healing was seen, with maintenance
of length and alignment.

amount of osteogenesis produced by

the marrow is directly related to its
cell density. The technique involves
harvesting bone marrow percutaneously from the iliac crest and injecting it directly into the area of the
tibial nonunion. This allows the
marrow to be used much like an autologous bone graft, but without the
attendant morbidity of open harvesting and surgical dissection at the
fracture site. Under fluoroscopic
control, a marrow needle is inserted
into the site of the nonunion or delayed union. The preferred location
is the well-vascularized posterior aspect of the fracture, where a standard posterolateral bone graft
would be performed. It is important
to remember that marrow injection

Vol 4, No 5, September/October 1996

is not a substitute for adequate stabilization of the fracture or correction

of malalignment.
Bone grafts are also indicated to
fill defects caused by cortical bone
loss. They can be used successfully
to treat as much as 6 cm of bone loss,
usually in combination with external
fixation. When there is more bone
loss, alternative techniques, such as
bone transport, may be more effective. The advantages of bone
grafting include its status as a timehonored and well-tested technique,
its success rate of 88% to 95%, and
the fact that no specialized equipment is needed. Nevertheless, there
are several disadvantages with this
method of treatment. Donor-site
morbidity is often underestimated;

grafting provides little opportunity

for deformity correction; bone-graft
incorporation can be slow; and supplemental immobilization is usually
necessary.

Plate Osteosynthesis
Although the use of plating techniques in the treatment of acute tibial fractures has decreased with the
introduction of interlocking tibial
nails, its use in posttraumatic reconstruction has increased in recent
years.21,22 The major advantage of
compression plating in the management of nonunion is the ability to
correct deformity, restore function,
and promote healing (Fig. 2). It can
be used in virtually any location
along the tibia, from the knee to the

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Tibial Nonunion

Fig. 2 A, Fourteen weeks after multiple blunt trauma, this closed, displaced, angulated tibial shaft fracture remained painful and nonunited.
B, Open reduction and internal fixation with plate osteosynthesis was performed without bone graft. A lag screw was used to increase interfragmental compression. C, Radiographs obtained at 15 months show uneventful fracture healing.

ankle; it obviates the need for a cast;

and it allows the patient to begin
mobilizing the knee, ankle, and subtalar joints.
There are several drawbacks with
the use of plate osteosynthesis, however. Internal fixation with plates
and screws involves a load-bearing
device that requires a period of protected weight bearing. Its use in patients with a compromised soft-tissue envelope or scarred, atrophic
skin increases the risk of wound
breakdown and infection. Additionally, in elderly patients and patients
with long-standing nonunions associated with severe osteopenia, plate
osteosynthesis may not provide stable internal fixation. Furthermore,
in the case of atrophic nonunions,
adjunctive bone grafting is always
necessary.
When applied to the convex surface of the nonunited tibia as a tension band, the plate can assist in cor-

254

rection of the deformity while

achieving stable internal fixation.
Tibial nonunions with deformities
that are correctable with a plate
should not be disturbed. Operative
mobilization of a nonunited tibia increases the instability at the fracture
site, impairs vascularity, and prolongs healing time. Takedown of a
nonunion is necessary only in patients who have excessive angulation or shortening, a true synovial
pseudarthrosis, or an infected
nonunion. In these difficult situations, alternative methods of treatment may be indicated.
In the middle three fifths of the
tibia, a plate should be applied to the
tension side of the bone, where it
will act as a tension band. With
varus deformities, the plate is applied laterally; with valgus deformities, the plate is applied medially.
Through an anterior approach, the
soft tissues are elevated only on the

side of the tibia where the plate is to

be applied. Circumferential stripping of the nonunion should be
avoided, except in patients who require major deformity correction. In
patients with stiff nonunions or substantial angulation, a fibular osteotomy often improves deformity
correction.
Adjunctive measures, such as use
of a femoral distractor or an articulated compression-distraction device, are extremely useful in minimizing soft-tissue dissection. It is
important to contour the plate to the
bone, rather than realigning the tibia
to the plate. Whenever possible, an
interfragmentary lag screw should
be placed across the nonunion site,
either separately or through the
plate, which will increase the stability of the nonunion and decrease rotational shear at the nonunion site.
In the diaphysis, we prefer 4.5mm titanium limited-contact dy-

Journal of the American Academy of Orthopaedic Surgeons

Donald A. Wiss, MD, and William B. Stetson, MD

namic-compression (LCDC) plates.

However, in the distal tibial metaphyseal region, the use of 3.5-mm titanium LCDC implants may be preferable. In most hypertrophic nonunions,
the mechanical stability provided by
a plate alone usually leads to rapid
consolidation of the fracture. In atrophic nonunions, the use of plate fixation together with autogenous bone
graft is necessary.
If there is a history of infection, aspiration biopsy should be considered before plating. If the culture is
positive, alternative methods of
treatment may be indicated.

Intramedullary Nailing
Closed intramedullary nailing
with reaming is perhaps the optimal
method of management for tibial
nonunions and delayed unions.23-26
It provides enough mechanical

strength to allow impaction without

angular deformity during weight
bearing. Reaming itself may act as a
stimulus to healing. Nailing also allows early active rehabilitation of
the muscles and joints of the lower
extremity without the need for an
external cast or brace (Fig. 3). Unfortunately, in many patients, the biological environment is not suitable
for a reamed intramedullary nail.
The use of a reamed intramedullary nail in the management of a
tibial nonunion is indicated in the
treatment of closed fractures and in
selected patients with prior grade I
and grade II open tibial fractures in
the middle three fifths of the bone.
The technique is also useful when
acute plating has failed and when
conversion from use of a nonreamed
tibial nail is necessary. Because of the
high rates of infection, reamed intra-

medullary nails should be used with

caution in patients with prior grade
III open tibial fractures, particularly
when initial management was with
external fixation. 23 Patients with
medullary canal malalignment that
necessitates open intramedullary
nailing are often better treated with
alternative techniques. In patients
with stiff hypertrophic nonunions
and substantial deformity, closed intramedullary nailing may be technically difficult or impossible.
Intramedullary nailing of tibial
nonunions can be a challenging surgical reconstruction. Previous experience in the management of acute fractures with reamed intramedullary
nails is helpful. In nonunions of longstanding duration, the medullary
canal is often occluded. In this situation, intramedullary pseudarthrosis
chisels may be necessary to open the

Fig. 3 A, Nine months after a grade I open tibial fracture with an intact fibula, nonunion was seen, with a 12-degree varus deformity. B,
Treatment consisted of placement of a reamed intramedullary interlocking nail and a fibular osteotomy. Despite the fibular resection, complete deformity correction was not achieved, leaving 7 degrees of residual varus angulation. C, At 1-year follow-up, the fracture had united
with an excellent functional result.

Vol 4, No 5, September/October 1996

255

Tibial Nonunion
canal before the guide wire can be
successfully passed. Nailing can be
done on a radiolucent table or on a
fracture table. A tourniquet should
not be used, to avoid thermal damage
during reaming. The reamings
should be cultured.
A nail with locking capabilities is
strongly recommended. Unlike
acute fractures, most tibial nonunions
have begun to heal and are inherently
stable after nailing without static
locking. In very proximal and distal
nonunions, the addition of locking
screws to increase stability in the
short fragment is often helpful. In
nonunions in the middle third, locking is usually not necessary.
The role of nonreamed tibial nails
in the management of established
nonunions remains investigational.27

Conventional External Fixation

Half-pin external fixation is used
primarily in the management of infected nonunions. Combined with
radical and repeated debridements,
soft-tissue reconstructive procedures, and adjunctive bone-grafting

techniques, external fixation remains

the mainstay of skeletal stabilization.
The use of a fixator that allows
loading at the nonunion site during
weight bearing may be mechanically
and biologically attractive. Advantages include the simplicity of the
unilateral half-pin technique and the
ability to achieve limited axial deformity correction. With some fixators,
segmental bone transport can be employed when indicated. The major
disadvantage with external skeletal
fixation is the need for prolonged
use and the virtual inevitability of
pin-tract infection.
The principal role of external fixation lies in the management of infected nonunions. The fixator allows
stabilization of the injury and debridement as necessary and facilitates
the reconstruction of soft tissues once
infection is under control. Its use in
aseptic nonunions is more limited.
However, it can be helpful in proximal and distal nonunions, previously
infected but quiescent nonunions,
and nonunions with a scarred or worrisome soft-tissue envelope.

Small-Wire and Hybrid External

Fixation
The use of small-wire circular fixators and hybrid external fixation in
the management of tibial nonunions
has grown in popularity.28 Indications include the presence of a periarticular nonunion, a tibial fracture
associated with bone loss, limb
shortening, or an infected nonunion
or the need for multiplanar deformity correction (Fig. 4).
The advantages of Ilizarov-type
fixation include percutaneous application with minimal blood loss,
wide application throughout the
length of the tibia, the potential to
achieve substantial deformity correction, and the ability to overcome
bone defects without grafting.
When properly applied, circular fixators provide stable fixation at multiple levels during distraction or
compression. Axial alignment can
be restored with the use of different
combinations of frame designs that
utilize hinges, beaded wires, and
push or pull constructs on the rings.
Stable fixation permits normaliza-

Fig. 4 A, Treatment of a grade IIIB open tibial fracture that became infected involved multiple procedures, including a free flap. Thirteen
months after injury, a complex-composite deformity remained, with 23 degrees of varus deformity and 3 cm of shortening. B, Treatment
with an Ilizarov external-fixation device. C, A corticotomy was made just proximal to the apex of the deformity to allow correction and leg
lengthening. D, Radiographs obtained at final follow-up at 19 months show restoration of length and alignment.

256

Journal of the American Academy of Orthopaedic Surgeons

Donald A. Wiss, MD, and William B. Stetson, MD

tion of function with early weight

bearing and range-of-motion potential for adjacent joints. This, in turn,
increases the vascularity of the entire
limb, thereby promoting healing.
Nevertheless, there are several
problems and disadvantages with
the use of circular fixators. These include the necessity of maintaining an
extensive inventory of equipment,
the cost of the appliance, the relatively high incidence of pin-tract
problems, the need for specialized
training in the method, and the long
learning curve. Furthermore, the

The management of severe open

fractures of the tibia remains one of
the more challenging problems fac-

ing the orthopaedic surgeon. Many

of these fractures fail to unite because of the severity of the initial
fracture displacement, the damage
to the surrounding soft tissues, and
the disruption of the microcirculation in the zone of injury. Failure to
achieve union may lead to multiple
surgical procedures, with months or
years of disability before union is obtained or amputation is performed.
Selecting a method of treatment is
difficult, and activation of subclinical infection remains a hazard after
surgical management.

9. Nepola JV, Seabold JE, Marsh JL, et al:

Diagnosis of infection in ununited fractures: Combined imaging with indium
111-labelled leukocytes and technetium-99m methylene diphosphonate.
J Bone Joint Surg Am 1993;75:1816-1822.
10. Beltran J, Noto AM, McGhee RB, et al:
Infections of the musculoskeletal system: High-field-strength MR imaging.
Radiology 1987;164:449-454.
11. Berquist TH, Brown ML, Fitzgerald RH
Jr, et al: Magnetic resonance imaging:
Application in musculoskeletal infection. Magn Reson Imaging 1985;3:219-230.
12. Modic MT, Pflanze W, Feiglin DHI, et al:
Magnetic resonance imaging of musculoskeletal infections. Radiol Clin North
Am 1986;24:247-258.
13. Mason MD, Zlatkin MB, Esterhai JL, et al:
Chronic complicated osteomyelitis of the
lower extremity: Evaluation with MR
imaging. Radiology 1989;173:355-359.
14. Gristina AG, Naylor PT, Webb LX: Molecular mechanisms in musculoskeletal
sepsis: The race for the surface. Instr
Course Lect 1990;39:471-482.
15. Sarmiento A, Latta LL: Closed Functional
Treatment of Fractures. Berlin: SpringerVerlag, 1981, pp 1-58.
16. Sharrard WJW: A double-blind trial of
pulsed electromagnetic fields for delayed union of tibial fractures. J Bone
Joint Surg Br 1990;72:347-355.
17. Scott G, King JB: A prospective, double
blind trial of electrical capacitive coupling
in the treatment of non-union of long bones.
J Bone Joint Surg Am 1994;76:820-826.
18. Simpson JM, Ebraheim NA, An HS, et
al: Posterolateral bone graft of the tibia.
Clin Orthop 1990;251:200-206.

19. Connolly JF, Guse R, Tiedeman J, et al:

Autologous marrow injection as a substitute for operative grafting of tibial
nonunions. Clin Orthop 1991;266:259270.
20. Garg NK, Gaur S, Sharma S: Percutaneous autogenous bone marrow grafting in 20 cases of ununited fracture.
Acta Orthop Scand 1993;64:671-672.
21. Wiss DA, Johnson DL, Miao M: Compression plating for non-union after failed
external fixation of open tibial fractures. J
Bone Joint Surg Am 1992;74:1279-1285.
22. Helfet DL, Jupiter JB, Gasser S: Indirect
reduction and tension-band plating of
tibial non-union with deformity. J Bone
Joint Surg Am 1992;74:1286-1297.
23. Wiss DA, Stetson WB: Nonunion of the
tibia treated with a reamed intramedullary
nail. J Orthop Trauma 1994;8:189-194.
24. Johnson KD: Management of malunion
and nonunion of the tibia. Orthop Clin
North Am 1987;18:157-171.
25. Mayo KA, Benirschke SK: Treatment of
tibial malunions and nonunions with
reamed intramedullary nails. Orthop
Clin North Am 1990;21:715-724.
26. Sledge SL, Johnson KD, Henley MB, et
al: Intramedullary nailing with reaming
to treat non-union of the tibia. J Bone
Joint Surg Am 1989;71:1004-1019.
27. Riemer BL, Butterfield SL: Comparison
of reamed and nonreamed solid core
nailing of the tibial diaphysis after external fixation: A preliminary report. J
Orthop Trauma 1993;7:279-285.
28. Schwartsman V, Choi SH, Schwartsman
R: Tibial nonunions: Treatment tactics
with the Ilizarov method. Orthop Clin
North Am 1990;21:639-653.

technique is not indicated for many

patients. Use of this method is relatively contraindicated in the treatment of patients who are psychologically impaired or emotionally
fragile and patients for whom compliance or close follow-up is not possible. It should also not be attempted
by a surgeon inexperienced in its use.

Summary

References
1. Wiss DA, Sherman R, Oechsel M: External skeletal fixation and rectus abdominis free-tissue transfer in the management of severe open fractures of the tibia.
Orthop Clin North Am 1993;24:549-556.
2. Fischer MD, Gustilo RB, Varecka TF:
The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial
shaft with extensive soft-tissue injury. J
Bone Joint Surg Am 1991;73:1316-1322.
3. Bach AW, Hansen ST Jr: Delayed union,
nonunion, and malunion of the tibial
shaft, in Evarts CM (ed): Surgery of the
Musculoskeletal System, vol 3. New York:
Churchill Livingstone, 1983, pp 8:63-8:86.
4. Gustilo RB, Mendoza RM, Williams DN:
Problems in the management of type III
(severe) open fractures: A new classification of type III open fractures. J
Trauma 1984;24:742-746.
5. Marsh J, Nepola J, Seabold J: Subclinical
infection in delayed nonunion of fractures
[abstract]. J Orthop Trauma 1989;3:169.
6. Esterhai J, Alavi A, Mandell GA, et al:
Sequential technetium-99m/gallium-67
scintigraphic evaluation of subclinical
osteomyelitis complicating fracture
nonunion. J Orthop Res 1985;3:219-225.
7. Smith MA, Jones EA, Strachan RK, et al:
Prediction of fracture healing in the tibia
by quantitative radionuclide imaging. J
Bone Joint Surg Br 1987;69:441-447.
8. Merkel KD, Brown ML, Dewanjee MK,
et al: Comparison of indium-labeledleukocyte imaging with sequential technetium-gallium scanning in the diagnosis of low-grade musculoskeletal sepsis:
A prospective study. J Bone Joint Surg
Am 1985;67:465-476.

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