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To report the outcomes of percutaneous autologous bone marrow injection for nonunion or delayed union of the distal tibial metaphysis in patients with prior plating.Consecutive case series.Tertiary center.Eleven consecutive patients (aged 24–51 years) were referred to us with a nonunion or delayed union of the distal tibial metaphysis after open reduction and internal fixation (plates and screws) at the time of fracture. The average time from initial injury to nonunion or delayed union and bone marrow treatment was 8 months (range, 3–20 months).A total of 40–80 mL of bone marrow aspirated from the posterior iliac crest and injected in and around the nonunion or delayed union site under fluoroscopic guidance.Healing at the injury site was evaluated using clinical and radiographic criteria, including computed tomography. Measures included American Academy of Orthopaedic Surgeons Lower Limb Core Scale (LLCS), Brief Pain Inventory, and Short Form 12 Physical Component Summary.Nine of the 11 patients attained bony union within 6 months of bone marrow injection. Six of these 9 patients who were followed-up an average of 4.4 years (range, 1.3–8.2 years) after the injection reported significant (P < 0.05) improvements in Lower Limb Core Scale (59.9–89.7), pain intensity (2.9–1.7), pain interference (4.6–2.3), and Short Form 12 Physical Component Summary (29.5–46.6) and 5.6 years improvement in quality-adjusted life years.Percutaneous autologous bone marrow injection is a minimally invasive, safe, and inexpensive treatment option for distal metaphyseal tibial nonunions or delayed unions after internal fixation and should be considered when the retained hardware seems to be intact and stable.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.