1. Soft Tissue and Biomechanical Challenges Encountered with the Management of Distal Tibia Nonunions 
Ivan S. Tarkin, MD, Peter A. Siska, MD, Boris A. Zelle, MD 
Orthopedic Clinics 
Volume 41, Issue 1, Pages (January 2010)
DOI: /j.ocl
Copyright © 2010 Elsevier Inc. Terms and Conditions

2. Fig. 1
Delayed union of high-energy open fracture of distal third tibia (A) treated with debridement flap, and minimally invasive plate osteosynthesis (B, C). Causes for delayed healing were multifactorial including open fracture, vascular insufficiency, poor nutrition (polytrauma patient), tobacco abuse. (D) Angiogram demonstrates arterial injury to the anterior and posterior tibial circulation.
Orthopedic Clinics  , DOI: ( /j.ocl )
Copyright © 2010 Elsevier Inc. Terms and Conditions

3. Fig. 2
Preoperative radiograph of oligotrophic distal tibia nonunion with varus deformity (A, B). Precise alignment of the anatomic/mechanical axis of the tibia achieved after debridement of the nonunion scar (C) and corrective fibular osteotomy (D). Peri-articular locking plate used to assist in deformity correction and for rigid fixation of the short osteopenic distal segment. Fibula rigidly fixed and used as biologic lateral column support. Compression of nonunion with interfragmentary compression (E). Central bone graft technique used. Patient healed at 4 months (F–H).
Orthopedic Clinics  , DOI: ( /j.ocl )
Copyright © 2010 Elsevier Inc. Terms and Conditions

4. Fig. 3
As an alternative to iliac crest autograft, bone graft can be harvested from the femoral canal using the reamer-irrigator-aspirator method (A, B).
Orthopedic Clinics  , DOI: ( /j.ocl )
Copyright © 2010 Elsevier Inc. Terms and Conditions

5. Fig. 4
Staged approach to infected distal tibia nonunion with bone loss. Previous exposed hardware removed, infected bone/soft tissue debrided, antibiotic beads placed, and free flap performed (A, B). After a course of organism-specific antibiotic therapy, definitive reconstruction performed using autogenous bone from the iliac crest and recombinant bone morphogenic protein (C).
Orthopedic Clinics  , DOI: ( /j.ocl )
Copyright © 2010 Elsevier Inc. Terms and Conditions