Secrets of Success in the Management of Lower Extremity Nonunions.

The key to obtaining healing of nonunions in the lower extremity is to provide a balance of biology and stability. To achieve this goal, the surgeon must understand why the bone did not heal with the initial treatment and change the strategy to improve the outcome. Patients need to be optimized before any proposed surgery. Whether the surgeon uses a certain type of internal or external fixation depends on the location on bone, the type (atrophic versus hypertrophic) of nonunion, the local soft tissue, the element of infection, and the health of the host. The mechanical stability of the fixation, especially in the lower extremity, should be robust and allow some early weight bearing. Early weight bearing stimulates healing, decreases osteoporosis, improves the patient's overall health, and allows early return to function. Diagnosis and management of infected nonunions in the lower extremity is also a major key to a successful outcome in this difficult group of patients.