Introduction: This video demonstrates posterolateral bone grafting with the use of iliac crest bone graft for the management of a distal tibial nonunion.

Methods: The patient shown in this video is a 42-year-old man who underwent surgical treatment for the management of an open distal tibia-fibula fracture 6 months ago. The patient reported persistent right ankle pain. The fracture site was tender to palpation, and three consecutive plain radiographs obtained 6 weeks apart demonstrated no evidence of callus formation.

Results: Posterolateral bone grafting of the tibial and fibular nonunion with the use of autogenous iliac crest bone graft was indicated. The plan was to create a synostosis between the fibula and tibia. Atrophic and oligotrophic nonunions are associated with poor biology to promote bone growth at the fracture site and benefit from the use of autogenous iliac bone graft, which is osteoinductive, osteoconductive, and osteogenic. Indications for posterolateral bone grafting of the tibia include atrophic or oligogrophic nonunion, an ipsilateral same-level tibial and fibular nonunion, or a tibial nonunion with a large anteromedial soft-tissue injury.

Conclusion: Posterolateral bone grafting with the use of iliac crest bone graft is a reliable method to achieve union in patients with a distal third tibia and fibula atrophic nonunion. Additional fixation or revision of fixation is not necessary in patients with injuries at high risk for nonunion who are followed closely and in whom treatment is performed in a timely manner if appropriate osteoinductive, osteoconductive, and osteogenic material is used to manage the nonunion.