The patient was taken to the operating room and given a general anesthetic. The lower extremity and anterior iliac crest were prepped in a sterile fashion. Antibiotics were administered after tissue from the nonunion was sent for culture.
An anterior incision was carried down to the periosteum and anterior compartment fascia. The anterior compartment fascia is incised 2-3 mm lateral to the tibial crest. This leaves a small cuff of periosteum / fascia on the crest of the tibia to repair the anterior compartment fascia with upon closure. The remainder of the dissection is extra-periosteal. Two millimeters of periosteum (scar) is removed on either side of the nonunion. The nonunion is debrided. The medullary canal is identified with removal of all the nonunion. The loose lag screw was removed. The Rush rod was removed with a small incision at the tip of the fibula.
The nonunion was reduced and held with pointed reduction forceps. Fluoroscopic examination demonstrated restoration of the anatomic axis. A bone graft was obtained from the anterior iliac crest. The pointed reduction clamp was removed and bone graft was packed into the proximal and distal canal of the tibia. Graft was also placed around the nonunion after fixation.
Two lag screws were placed across the nonunion. Stability with restoration of the anatomic axis was achieved. The guide for the cannulated blade plate was placed along the anterior medial distal tibia. A guide wire was inserted into the distal fragment and it's position was verified with fluoroscopy. The guide wire was measured to obtain the correct length of the blade.
A longer plate was needed to neutralize the lag screws. In this titanium cannulated blade plate set longer plates have longer blades. Thus, the blade would have to be shortened. A carborundum metal cutting saw was used to cut the blade to the size measured with the guide wire. The distal fragment was drilled using the guide and the blade plate inserted. The plate was bent to fit. The plate position was verified with fluoroscopy. The distal cancellous was placed first. An eccentric screw was then added proximally to place the plate under tension. The remainder of the screws were then added. Radiographs (Figure 6) were obtained that demonstrated anatomic restoration of the mechanical axis of the tibia.
A drain was placed and the wound closed in layers after irrigation. A bulky compressive dressing was applied. The total tourniquet time was less than two and one-half hours.