Tibial fracture nonunion is expensive in terms of health-care and personal costs. Compared with patients with a healed tibial fracture, those with a nonunion have poorer physical and mental function and more posttraumatic psychological distress. Reliance on walking aids and opioids is commonly associated with tibial nonunion.

In the present study, quality of life was measured in a heterogeneous cohort of patients with tibial shaft nonunion at three to 244 months after injury; these patients had undergone zero to twenty-three operations. Although there was no matched cohort of patients with a healed tibial shaft fracture for comparison, the authors compared their outcomes with the normal population and patients with other health conditions such as chronic cardiovascular disease and arthritis. They found that patients with nonunion, on average, reported physical health worse than 90% of the normal population and mental health worse than 75% of the normal population. This is below the quality of life experienced by many individuals living with diabetes and those who have survived myocardial infarction. Patients with tibial shaft nonunion who also had depression, obesity, and diabetes (especially in combination) reported particularly poor function and high levels of chronic pain. Although smoking has been well established as a risk factor for the development of nonunion, the current study revealed that patients with nonunion who smoked had similar function to those with nonunion who did not smoke.

Given the profound deficits in quality of life experienced by individuals with tibial nonunion, attempts should be focused on prevention and timely, effective treatment. Zlowodzki et al. showed that, one year after successful treatment of tibial nonunion, Short Form (SF)-36 physical and social function scores had improved significantly from the values before treatment, although others found less improvement in SF-36 scores despite eventual fracture-healing.

The best evidence to date suggests that statically locked, reamed intramedullary nailing of both open and closed tibial shaft fractures is associated with the best outcomes, including minimizing the risk of nonunion. For those with delayed union following tibial shaft fracture, smoking cessation and avoidance of chronic nonsteroidal anti-inflammatory drug use may be helpful in maximizing the likelihood of achieving union with well-planned and well-executed surgical treatment. For established tibial nonunions, nonsurgical treatment alone (such as pulsed ultrasound or interferential current) is not likely to succeed.