External fixation for the uninfected angulated nonunion of the tibia

External skeletal fixation is an effective method of stabilizing angulated ununited fractures of the tibia. In 14 patients who were not infected, realignment was accomplished by: closed-fracture-site manipulation (five cases); fibular osteotomy and closed manipulation (six cases); or fibular osteotomy and open reduction (three cases). External fixation was selected instead of internal fixation for patients in whom there was: risk of reactivating quiescent sepsis; thin secondary epithelium adherent to bone that might slough after surgical dissection; a very proximal or a very distal nonunion, where internal fixation is technically difficult; or a bulky, angulated delayed union or nonunion or one in bayonet apposition that would require excessive plate contouring. On the average, patients were corrected from 17.3 degrees (either varus or valgus) to 2.3 degrees. Two patients did not unite with the fixator/orthosis treatment plan, but neither one lost correction during subsequent management. The technique is not suitable for atrophic nonunions.