[1/11] Nonunion teaching case. These are my most challenging/frustrating but rewarding cases. Injured 5 months ago—not quite 9 month FDA definition but fit Brinker (“unlikely to heal without intervention in surgeon’s opinion”). Leg floppy, varus and externally rotated 90 degrees. 
[2/11] Although this seemed like clear case of undertreated hypertrophic nonunion with stability issue, CRP slightly elevated so I did 2-stage. First was bone biopsy and cultures, which were negative. It also showed how big metaphyseal gap is once hypertrophic bone cleared out.
[3/11] 2nd stage involved standard lateral approach to proximal tibia, and medial approach at the “spike.” Bone cleared out both ways and here you can see the attempt to mobilize things. It doesn’t work completely; that happens when soft tissues contract after long time in varus.
[4/11] Here you can see attempt to clamp, which resolves varus but leaves translation deformity (left). This forced me to osteotomize old proximal fibula fracture (right); I don’t like going there but hoped would help me mobilize further. The nerve had been in palsy for months.
[5/11] I then planned a screw below medial spike, hoping to resolve translation that way. The plate was stout 3.5 pre-contoured, as I needed stiffness to make this work. While I slowly turned the (intentionally long) “working screw,” assistant pulled traction and pushed valgus.
[6/11] Initial screw didn’t have great bite, so screw above it acted as working screw. As it cinched down, plate pushed proximal fragment over and pulled tibia shaft to plate, making leg straight. This was also done with tibia rotated back into position out of external rotation.
[7/11] Proximal piece secured briefly w/wire, then lateral view checked. There was extension deformity, addressed w/clamp. Not aiming for perfect; some hypertrophic bone could not be cleared posterior (risk to vessels). Also had malunited tubercle w/attached tendon; left alone.
[8/11] Joint had residual varus tilt, addressed this by making locking construct of plate & proximal fragment, then used plate as lever; as plate secured distal, joint back into better position. Good thing is lateral plate fit well (w/metaphyseal gap), which means alignment good.
[9/11] Video of how the lateral plate was used to lever the joint back into normal. Note the medial wire was removed from the proximal fragment to allow it to move. (Yes, the “working screw” medial is still long, that gets removed eventually and replaced with shorter screw.)
[10/11] Once alignment restored, more locking screws in proximal fragment and rest of screws as usual. Note large metaphyseal gap (filled w/graft) & slight remaining extension deformity on lateral, which could not fix without osteotomy of tubercle, which would not have been wise.
[11/11] Cases like this require planning and patience, particularly debridement of nonunion tissue. That will make or break your case; do not rush that step and make sure you get healthy bleeding bone before you address fixation. Patient also must be aware of the risks involved.
