Les auteurs présentent leur expérience concernant le traitement des pseudarthroses après enclouage pour fracture de jambe par une technique associant la décortication ostéopériostée à une ostéosynthèse par plaque médiale. Dix huit cas de pseudarthroses aseptiques tibiales après enclouage ont été traités chez 18 patients d'âge moyen de 39 ans. Huit fractures étaient initialement ouvertes. La technique de décortication décrite par Robert Judet en 1967, garde ici des indications, associée à l'ostéosynthèse interne car elle permet de relancer l'ostéogenèse par une autogreffe locale et permet également la correction des attitudes vicieuses préopératoires. Ceci avec des taux de succès satisfaisants tant sur la consolidation que sur la correction des attitudes vicieuses. En effet, 7 des 18 patients ont consolidé per-primam. Parmi les 13 patients qui présentaient une position vicieuse initiale associée à la pseudarthrose, 6 ont pu être complètement corrigés, 7 gardaient un défaut angulaire de moins de 6° dans 5 cas et supérieur à 10° dans 2 cas. Six autres cas ont eu une correction complète. Aucune nécrose cutanée n'a été déplorée. Dans tous les cas, la raideur articulaire préopératoire particulièrement de cheville a été améliorée après le traitement.

La décortication permet une relance de l'ostéogenèse. L'ouverture du foyer permet une réduction précise. Quant à l'ostéosynthèse par plaque, elle n'a pas été délétère.

Intramedullar nailing is now widely used for fractures of the tibia. Extension of nailing indications to proximal, distal, and comminuted fractures has led to a significant rate of complications. The purpose of this study was to analyze decortication and medial plating for the treatment of tibial nonunion after intramedullary nailing.

Eighteen cases of aseptic tibial nonunion after nailing for fracture were treated in three women and fifteen men, mean age 39 years (19-57). The initial classification was open (n = 8), segmental (n = 3), single-focus (n = 15). The fracture site was inferior (n = 6), middle (n = 7), and superior (n = 2). Primary nailing used reaming in 15 cases (83%), unreamed in 3 (17%) static in 13 and dynamic in 5. Four plaster cabts were also applied. Complications were: infection (n = 1), compartmental syndrome (n = 2), tibial nerve palsy (n = 1), dysesthesia (n = 2), and protrusion of the nail into the knee (n = 1). Dynamization was performed in 11 patients, one with additional bone graft and fibulectomy. Repeated reamed nailing was performed in one patient. Seven nonunions were atrophic and 11 were hypertrophic. There were 13 malpositionings associated with the nonunion. Treatment of the nonunion was performed 300 days on average (90-900) after nailing: cancellous bone graft was associated with decortication in four cases because of bone loss (n = 3) or atrophic nonunion (n = 1).

Union rate was 94%. Mean time for union was 108 days (80-180) with no significant difference (Student t-test) between atrophic (119 days) and hypertrophic (103 days) nonunion. Correction of the malposition was incomplete in seven patients, with angular malunion of less than 6° in five patients and greater than 10° in two. One late infection occurred and finally healed after external fixation and antibiotic therapy. No skin necrosis occurred. Five patients had pain on the hardware. Removal was performed in one time and pain resolved. Improvement of knee and ankle stiffness was achieved in all patients.

This technique has been used in our department since 1967. Different studies have found a union rate ranging from 94% to 100% with this procedure. Intramedullary nailing, sometimes associated with bone graft or decortication, is also used for tibial nonunion with a good rate of union. The main problem of intramedulary nailing for nonunion, as for fracture, is the difficulty in avoiding malunion. Plating a nonunion, as a fracture, enables better reduction. Skin problems can occur with the medial plate if the soft tissues are damaged. This situation is very uncommon in secondary surgery.

Decortication and medial plating was a safe and efficient treatment for tibia nonunion after failure of intramedullary nailing and allows better reduction and repeated nailing.