Muller reports a 100-case series treating long-bone shaft nonunions with rigid internal fixation. Compression plating and intramedullary nailing are the two main methods, with grafting reserved for select cases. The paper defines when each technique and when a bone graft is indicated.
When you face a nonunion, the first question is not whether to graft but whether you have achieved rigid fixation. Muller's core argument is that rigid stability alone heals a viable nonunion, and no mysterious osteogenic stimulus is required.
The decision rule to memorize: graft only the avascular (inert) pseudarthrosis. A hypervascular 'elephant's foot' nonunion has living, reactive bone and will ossify under compression without excising the scar tissue.
This operationalizes AO principles you will see on the OITE: interfragmentary compression, plate on the tension side (lateral tibia), and nailing reserved for diaphyseal fractures with normal axes. The failures are the real teaching tool. Each one violated a rule, medial plate placement, ungrafted inert bone, or an undersized nail, and each corrected once the rule was followed.
The wider point still holds: rigid fixation lets you mobilize joints early and fear stiffness more than the nonunion.
Muller reports a 100-case series treating long-bone shaft nonunions with rigid internal fixation. Compression plating and intramedullary nailing are the two main methods, with grafting reserved for select cases. The paper defines when each technique and when a bone graft is indicated.
When you face a nonunion, the first question is not whether to graft but whether you have achieved rigid fixation. Muller's core argument is that rigid stability alone heals a viable nonunion, and no mysterious osteogenic stimulus is required.
The decision rule to memorize: graft only the avascular (inert) pseudarthrosis. A hypervascular 'elephant's foot' nonunion has living, reactive bone and will ossify under compression without excising the scar tissue.
This operationalizes AO principles you will see on the OITE: interfragmentary compression, plate on the tension side (lateral tibia), and nailing reserved for diaphyseal fractures with normal axes. The failures are the real teaching tool. Each one violated a rule, medial plate placement, ungrafted inert bone, or an undersized nail, and each corrected once the rule was followed.
The wider point still holds: rigid fixation lets you mobilize joints early and fear stiffness more than the nonunion.