Failed Periarticular Fracture Revision - How Would You Treat?

This young patient was 6 months out from my treatment of an open pilon fracture, presenting with pain and swelling. The soft tissues were in good condition. There were no signs of infection and labs were normal. Images showed callus but also loss of coronal alignment, nonunion, and broken implants. The injury and immediate postop films are available for review.

Step 1: Is this an extra-articular or intra-articular problem? This one has a healed joint and is an extra-articular issue.

Step 2: Mechanical or biologic problem? Primarily a mechanical problem.

-           Uni-columnar bridge plate likely insufficient to last for the entire duration of healing.
-           Progressive loss of coronal alignment worsened the environment  The biology was affected by initial injury but presence of callus and hypertrophic nonunion suggests it is not the dominant issue

Treatment strategy:
-           Remove failed implants
-           Restore alignment with a medially based frame
           Stabilize with medullary nail

Reaming stimulated the biology, but the key intervention is mechanical optimization

This led to reliable healing in this case. In my experience, medullary nailing with realignment is an excellent option for hypertrophic extra-articular pilon nonunion.

What are your thoughts on this problem?

Do you like medullary nailing?

Any other good treatment options?