{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T11:22:04Z","timestamp":1783077724679,"version":"3.54.6"},"reference-count":14,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T00:00:00Z","timestamp":1783036800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Clinics and Practice"],"abstract":"<jats:p>Background: Congenital fibular deficiency is a rare longitudinal deficiency of the lower extremity associated with limb-length discrepancy, ankle and foot deformity, soft-tissue imbalance, and functional impairment. Reconstruction may be challenging because bone healing, regenerate maturation, and mechanical stability can be less predictable in selected patients. Case Presentation: A man with congenital fibular deficiency developed chronic distal tibial nonunion after corrective osteotomy at another institution. The nonunion persisted for four years, and the patient presented to our hospital with inability to bear weight and wheelchair dependence. A comprehensive salvage strategy was performed, including Achilles tendon lengthening using the Vulpius technique, removal of retained fixation material, debridement and refreshment of the nonunion site, negative bacteriological cultures, autologous cancellous iliac bone grafting, acute shortening and compression of the docking site, circular external fixation, proximal tibial osteotomy, and gradual lengthening. Low-intensity pulsed ultrasound was applied postoperatively as an adjunctive biological stimulus. Results: Bone union was achieved, and the external fixator was removed approximately one year after surgery. A total lengthening of 78 mm was achieved. At 12-year follow-up, the AOFAS ankle-hindfoot score was 90, ankle range of motion was 5\u00b0 dorsiflexion and 40\u00b0 plantarflexion, and the JOA knee score was 95. The patient walked independently without assistive devices and continued to work. Mild residual varus deformity of the proximal tibia was present, but the patient reported no knee pain, ankle pain, or ankle instability, and radiographs showed no progressive osteoarthritic changes. Conclusions: In selected patients with congenital fibular deficiency and chronic nonunion after previous treatment, durable limb salvage may be achieved using an individualized strategy that addresses both biological and mechanical factors.<\/jats:p>","DOI":"10.3390\/clinpract16070125","type":"journal-article","created":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T07:59:47Z","timestamp":1783065587000},"page":"125","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Limb Salvage After Chronic Nonunion Following Deformity Correction in Congenital Fibular Deficiency: A Cautionary 12-Year Follow-Up Case Highlighting Biological and Mechanical Reconstructive Challenges"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0238-8929","authenticated-orcid":false,"given":"Koji","family":"Nozaka","sequence":"first","affiliation":[{"name":"Department of Orthopaedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6209-3394","authenticated-orcid":false,"given":"Shohei","family":"Murata","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5175-3350","authenticated-orcid":false,"given":"Naohisa","family":"Miyakoshi","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1016\/S0030-5898(20)31702-8","article-title":"Management of fibular hemimelia using the Ilizarov method","volume":"22","author":"Catagni","year":"1991","journal-title":"Orthop. Clin. N. Am."},{"key":"ref_2","first-page":"46","article-title":"Management of fibular hemimelia with the Ilizarov circular external fixator","volume":"39","author":"Yildiz","year":"2005","journal-title":"Acta Orthop. Traumatol. Turc."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1144","DOI":"10.2106\/JBJS.J.00683","article-title":"Congenital fibular deficiency: A review of thirty years\u2019 experience at one institution and a proposed classification system based on clinical deformity","volume":"93","author":"Birch","year":"2011","journal-title":"J. Bone Jt. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"246","DOI":"10.5435\/JAAOS-22-04-246","article-title":"Congenital fibular deficiency","volume":"22","author":"Hamdy","year":"2014","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1007\/s11832-016-0790-0","article-title":"Surgical reconstruction for fibular hemimelia","volume":"10","author":"Paley","year":"2016","journal-title":"J. Child. Orthop."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Fuller, C.B., Shannon, C.E., and Paley, D. (2021). Lengthening reconstruction surgery for fibular hemimelia: A review. Children, 8.","DOI":"10.3390\/children8060467"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1097\/00003086-198902000-00029","article-title":"The tension-stress effect on the genesis and growth of tissues: Part II. The influence of the rate and frequency of distraction","volume":"239","author":"Ilizarov","year":"1989","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1097\/00003086-199001000-00003","article-title":"Clinical application of the tension-stress effect for limb lengthening","volume":"250","author":"Ilizarov","year":"1990","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e3787","DOI":"10.1097\/MD.0000000000003787","article-title":"Clinical results and complications of lower limb lengthening for fibular hemimelia: A report of eight cases","volume":"95","author":"Mishima","year":"2016","journal-title":"Medicine"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1177\/107110079401500701","article-title":"Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes","volume":"15","author":"Kitaoka","year":"1994","journal-title":"Foot Ankle Int."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"797","DOI":"10.2106\/JBJS.G.01297","article-title":"Adult outcomes following amputation or lengthening for fibular deficiency","volume":"91","author":"Walker","year":"2009","journal-title":"J. Bone Jt. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"b351","DOI":"10.1136\/bmj.b351","article-title":"Low intensity pulsed ultrasonography for fractures: Systematic review of randomized controlled trials","volume":"338","author":"Busse","year":"2009","journal-title":"BMJ"},{"key":"ref_13","first-page":"i5351","article-title":"Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): Randomized clinical trial","volume":"355","author":"Busse","year":"2016","journal-title":"BMJ"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1339","DOI":"10.1016\/j.injury.2017.05.016","article-title":"Healing of fracture nonunions treated with low-intensity pulsed ultrasound (LIPUS): A systematic review and meta-analysis","volume":"48","author":"Leighton","year":"2017","journal-title":"Injury"}],"container-title":["Clinics and Practice"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2039-7283\/16\/7\/125\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T10:46:22Z","timestamp":1783075582000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2039-7283\/16\/7\/125"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,3]]},"references-count":14,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["clinpract16070125"],"URL":"https:\/\/doi.org\/10.3390\/clinpract16070125","relation":{},"ISSN":["2039-7283"],"issn-type":[{"value":"2039-7283","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,3]]}}}