Tibial diaphyseal nonunions after external fixation treated with nonreamed solid core nails

Twenty-nine patients with tibial diaphyseal fractures had external fixators applied to treat their initial fractures and underwent nonreamed solid core nailing for nonunion (> 22 weeks). Fifteen Alta, 11 Lottes, and 3 Rush nails were used. The original fracture grades were: 1 closed, 1 grade I, 7 grade II, 3 grade IIIA, and 17 grade IIIB. The duration of nonunion was 51 weeks (average: 22 to 173). The average duration of external fixation was 19 weeks (range: 9 to 47). The average interval from fixator removal to nail was 32 weeks (range: 0 to 156). Twenty-eight patients were seen at > 12 months' follow up (average: 35; range: 10 to 58) and completion of treatment. Twenty-seven patients' fractures united at an average of 14 weeks (range: 6 to 40). One patient required a reamed exchange nailing at 39 weeks and united 58 weeks post-exchange nailing. One patient had a persistent asymptomatic nonunion. One patient developed a stress fracture 49 months post nail requiring an exchange nailing. Eleven fractures had a pre-nail deformity of 10 degrees or more; 9 were corrected. Eight patients had pre-nail wound and five had pre-nail pin tract infections. Except for two cases, all of these infections were treated successfully with surgical debridement and/or antibiotics prior to nail insertion. Two patients had their nail inserted through active infections that could not be controlled with an unstable fracture. One patient healed uneventfully in 6 weeks. One required two subsequent debridements. There were no other infections. The authors conclude that nonreamed solid core nailing is an acceptable treatment for tibial diaphyseal nonunions following external fixation.