Intramedullary nailing of aseptic tibial nonunions without the use of the fracture table.

Twenty-seven patients with 28 aseptic nonunions were treated with reamed intramedullary (IM) nailing of the tibia and were followed for at least 1 year postoperatively. The management protocol called for a radiolucent operating room table with the limb draped free and manual manipulation of the nonunion with a preference for closed nailing. Nail interlocking was used when residual axial or rotational instability was observed after nail insertion. Iliac crest bone grafting was performed on all patients requiring open nailing. Closed nailing, using the described technique, was accomplished in 20 cases; open nailing was necessary in eight. Although operative time and total blood loss were significantly increased with open nailing, time to union was similar in the two groups. Twenty-seven nonunions healed. The lone persistent nonunion responded to bone grafting, leaving the nail in situ. One infection occurred, which responded to debridement, drainage, and long-term antibiotic therapy without requiring nail removal. Acceptable bony alignment was attained in all patients. Functional results were excellent. This method is recommended for all tibial nonunions amenable to IM nail stabilization. A history of prior acute infection and/or excessive shortening due to bone loss constitute the relative contraindications.