Treatment options for aseptic tibial diaphyseal nonunion: A review of selected studies

In aseptic tibial diaphyseal nonunions after failed conservative treatment, the recommended treatment is a reamed intramedullary (IM) nail. Typically, when an aseptic tibial nonunion previously treated with an IM nail is found, it is advisable to change the previous IM nail for a larger diameter reamed and locked IM nail (the rate of success of renailing is around 90%). A second change after an IM nail failure is also a good option, especially if bone healing has progressed after the first change. Fibular osteotomy is not routinely advised; it is only recommended when it interferes with the nonunion site. In delayed unions before 24 weeks, IM nail dynamization can be performed as a less invasive option before deciding on a nail change. If there is a bone defect, a bone graft must be recommended, with the gold standard being the autologous iliac crest bone graft (AICBG). A reamer-irrigator-aspirator (RIA) system might also obtain a bone autograft that is comparable to AICBG. Although the size of the bone defect suitable to perform bone transport techniques is a controversial issue, we believe that such techniques can be considered in bone defects > 3 cm. Non-invasive therapies and biologic therapies could be applied in isolation for patients with high surgical risk, or could be used as adjuvants to the aforementioned surgical treatments. Cite this article: EFORT Open Rev 2020;5:835-844. DOI: 10.1302/2058-5241.5.190077