Treatment of Nonunited Fibular Diaphyseal Fracture at 3 Months
Surgical fixation with open reduction and internal fixation (ORIF) using plate and screw osteosynthesis plus autologous bone grafting is the definitive treatment for your symptomatic fibular nonunion causing pain with push-off during ambulation.
Rationale for Surgical Intervention
Your clinical presentation—persistent pain at 3 months with functional impairment during push-off—indicates a symptomatic nonunion requiring operative management. The pain you're experiencing results from micromotion strain at the incomplete fracture site during weight-bearing activities 1. Conservative management has already failed (3 months is adequate trial), and continued nonoperative treatment is unlikely to achieve union 2.
Key Clinical Evidence
The most recent systematic review (2026) analyzing 183 patients with fibular nonunion demonstrates that surgical treatment achieves favorable radiographic healing rates in symptomatic cases, while conservative treatment should be reserved only for asymptomatic or minimally symptomatic patients 3. Your case clearly falls into the surgical category given your functional pain.
Surgical Technique Specifics
The procedure should include:
- Open reduction and internal fixation with plate and screw fixation (preferred over intramedullary flexible nails for diaphyseal fractures)
- Autologous bone grafting from the iliac crest—this was performed in all but 2 cases in a key study and is critical for nonunion healing 2
- Complete debridement of the nonunion site to healthy bleeding bone
Evidence Supporting This Approach
A 2004 study of symptomatic fibular nonunions treated with plate osteosynthesis and bone grafting showed 100% of patients had complete pain resolution and return to normal gait within an average of 2.3 months postoperatively 1. A 2013 study confirmed that all nonunions healed with an average time to union of 5.2 months post-surgery, with patients achieving similar outcomes to those who underwent acute fracture fixation 2.
Why Not Conservative Management?
Do not pursue further conservative treatment (casting, bracing, or observation) at this point. You've already had 3 months of failed conservative care. The 2026 systematic review explicitly states that conservative treatment is appropriate only for asymptomatic or minimally symptomatic patients—which you are not 3. Your pain with push-off indicates mechanical instability requiring stabilization.
Why Not Low-Intensity Pulsed Ultrasound (LIPUS)?
Avoid LIPUS entirely. The 2017 BMJ clinical practice guideline provides strong evidence (moderate to high certainty) that LIPUS has little or no impact on fracture healing, pain, or time to return to function 4. The guideline panel unanimously agreed that all informed patients would elect not to use LIPUS, and it represents an inefficient use of healthcare resources 4.
Expected Outcomes
Based on the literature:
- Time to union: 5.2 months post-surgery on average 2
- Pain resolution: 2.3 months postoperatively 1
- Union rate: Essentially 100% with proper surgical technique 1, 2
- Complication rate: Low (3.8%), mainly minor infections and hardware issues 3
Postoperative Protocol
- Immediate mobilization with partial weight-bearing initially
- Full weight-bearing at 6 weeks
- Return to normal activities typically by 12 weeks 5
Common Pitfalls to Avoid
- Delaying surgery further: Prolonged nonunion increases soft tissue scarring and may compromise outcomes
- Inadequate bone grafting: Autologous bone graft is essential—don't skip this step
- Using intramedullary fixation alone: For diaphyseal nonunions, plate fixation provides superior stability compared to flexible nails 6
- Pursuing adjunctive therapies like LIPUS: These add cost and burden without benefit 4
Surgical Timing
Proceed with surgery as soon as feasible. At 3 months with persistent symptoms, you've met the criteria for nonunion diagnosis and failed conservative management. Further delay offers no benefit and prolongs your disability.
The distal fibular location (if that's your fracture site) carries a slightly higher nonunion risk (25% in one study) 6, but this makes surgical intervention even more appropriate given your symptoms. The evidence consistently shows that operative treatment of symptomatic fibular nonunions leads to reliable healing and functional restoration 1, 2, 3.