{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T07:16:00Z","timestamp":1788419760110,"version":"build-2803163510"},"reference-count":26,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T00:00:00Z","timestamp":1788393600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Surg."],"abstract":"<jats:p>Concept of \u201cmechanical\u2013biological balance\u201d is fundamental to successful fracture healing; disruption of either component can lead to healing failure. Fractures of the middle and distal tibia are commonly encountered in clinical practice, particularly when associated with comminution. Managing fracture nonunion requires a comprehensive assessment of infection status, skeletal alignment, bone defect, implant stability, and host biological characteristics. This case report aims to explore the etiological factors of tibial nonunion and to reflect upon the biomechanical mechanisms underlying internal fixation failure. The findings demonstrate that failure to restore structural stability rendered subsequent biological repair measures ineffective.<\/jats:p>\n                  <jats:sec>\n                    <jats:title>Case presentation<\/jats:title>\n                    <jats:p>A 49-year-old perimenopausal woman developed tibial nonunion after internal fixation with a medial locking plate, screws, and titanium cables for a comminuted mid-to-distal tibiofibular fracture. Despite subsequent revision with PRP injection and autologous iliac crest bone grafting without addressing the underlying mechanical instability, the nonunion persisted and ultimately resulted in plate fatigue fracture<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This case underscores that mechanical stability is a prerequisite for the biological cascade of fracture healing. In the absence of an adequate mechanical environment, even the most advanced biological augmentation cannot ensure successful union.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fsurg.2026.1891731","type":"journal-article","created":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T06:42:03Z","timestamp":1788417723000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Case Report: Management of tibial fracture nonunion: a case study of treatment failure and lessons learned"],"prefix":"10.3389","volume":"13","author":[{"given":"Chaoshuai","family":"Wang","sequence":"first","affiliation":[{"name":"The First Clinical Medical College, Shandong University of Traditional Chinese Medicine","place":["Jinan City, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chen","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, The Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine","place":["Jinan City, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,3]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"120","DOI":"10.4103\/jips.jips_62_17","article-title":"Demineralized dentin matrix scaffolds for alveolar bone engineering","volume":"17","author":"Um","year":"2017","journal-title":"J Indian Prosthodont Soc"},{"key":"B2","doi-asserted-by":"publisher","first-page":"835","DOI":"10.1302\/2058-5241.5.190077","article-title":"Treatment options for aseptic tibial diaphyseal nonunion: a review of selected studies","volume":"5","author":"G\u00e1lvez-Sirvent","year":"2020","journal-title":"EFORT Open Rev"},{"key":"B3","doi-asserted-by":"publisher","first-page":"S3","DOI":"10.1016\/j.injury.2020.11.029","article-title":"Fracture nonunion in long bones: a literature review of risk factors and surgical management","author":"Nicholson","year":"2021","journal-title":"Injury"},{"key":"B4","doi-asserted-by":"publisher","first-page":"159","DOI":"10.11622\/smedj.2021036","article-title":"Menopausal osteoporosis: screening, prevention and treatment","volume":"62","author":"Yong","year":"2021","journal-title":"Singapore Med J"},{"key":"B5","doi-asserted-by":"publisher","first-page":"321","DOI":"10.1186\/s13018-022-03216-z","article-title":"Aseptic nonunion of the tibia treated by plating and bone grafting: retrospective study about 40 cases","volume":"17","author":"Chmali","year":"2022","journal-title":"J Orthop Surg Res"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1573679","DOI":"10.3389\/fsurg.2025.1573679","article-title":"Clinical outcomes of tibial nonunion treatment through the combination of PRP, autogenous iliac bone grafting, and augmentation plating","volume":"12","author":"Lu","year":"2025","journal-title":"Front Surg"},{"key":"B7","doi-asserted-by":"publisher","first-page":"771252","DOI":"10.3389\/fmed.2021.771252","article-title":"Clinical effectiveness of platelet-rich plasma for long-bone delayed union and nonunion: a systematic review and meta-analysis","volume":"8","author":"Li","year":"2022","journal-title":"Front Med (Lausanne)"},{"key":"B8","doi-asserted-by":"publisher","first-page":"289","DOI":"10.1159\/000114967","article-title":"Benefit of percutaneous injection of autologous platelet-leukocyte-rich gel in patients with delayed union and nonunion","volume":"40","author":"Bielecki","year":"2008","journal-title":"Eur Surg Res"},{"key":"B9","doi-asserted-by":"publisher","first-page":"775","DOI":"10.1111\/j.1600-051X.2009.01450.x","article-title":"Effect of platelet-rich plasma on bone healing of autogenous bone grafts in critical-size defects","volume":"36","author":"Nagata","year":"2009","journal-title":"J Clin Periodontol"},{"key":"B10","doi-asserted-by":"publisher","first-page":"512","DOI":"10.1186\/s12891-022-05375-w","article-title":"Cortical allograft strut augmented with platelet-rich plasma for the treatment of long bone non-union in lower limb- a pilot study","volume":"23","author":"Wu","year":"2022","journal-title":"BMC Musculoskelet Disord"},{"key":"B11","doi-asserted-by":"publisher","first-page":"E8","DOI":"10.3171\/2021.3.FOCUS2148","article-title":"Bone grafting and biologics for spinal fusion in the pediatric population: current understanding and future perspective","volume":"50","author":"Letchuman","year":"2021","journal-title":"Neurosurg Focus"},{"key":"B12","doi-asserted-by":"publisher","first-page":"507","DOI":"10.1016\/j.jos.2023.01.006","article-title":"Biological reconstruction for massive bone defect following resection of tumor in Japan","volume":"28","author":"Nishida","year":"2023","journal-title":"J Orthop Sci"},{"key":"B13","doi-asserted-by":"publisher","first-page":"111824","DOI":"10.1016\/j.injury.2024.111824","article-title":"How difficult is titanium plate and screw implant removal? 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