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Background <p>Long-bone nonunion is multifactorial and may involve mechanical instability, local biological compromise, and potentially modifiable metabolic abnormalities. We report a rare case of atrophic tibial shaft nonunion in a young elite skier with severe vitamin D deficiency and elevated undercarboxylated osteocalcin, treated using an integrated biological and mechanical strategy.</p> Case presentation <p>A 28-year-old Japanese female elite skier sustained a high-energy skiing injury resulting in a Schatzker type VI tibial plateau fracture with an associated tibial shaft fracture. Initial treatment at another hospital consisted of plate fixation for the tibial plateau fracture and intramedullary nailing for the tibial shaft fracture. Painful atrophic tibial shaft nonunion persisted for 18&#xa0;months, and she was referred to our institution. Radiographs showed 7° varus deformity, 3° anterior convexity, and a femorotibial angle of 180°. Metabolic evaluation revealed severe vitamin D deficiency, with serum 25-hydroxyvitamin D below the measurable range (&lt; 7&#xa0;ng/mL), and elevated undercarboxylated osteocalcin (11.2&#xa0;ng/mL), suggesting vitamin K insufficiency in bone metabolism. Revision surgery consisted of implant removal, graft-free chipping of the tibial and fibular nonunion sites, acute correction using a Taylor Spatial Frame, olive-wire compression, and circular fixation allowing immediate postoperative weight-bearing. Postoperative alignment was corrected to 2° valgus, 7° recurvatum, and a femorotibial angle of 175°. Union was achieved, and the frame was removed at 5&#xa0;months. The patient later underwent anterior cruciate ligament reconstruction for an unrelated sports injury and returned to competitive skiing within 1&#xa0;year. At the 10-year follow-up, solid union was maintained, knee range of motion was 0°–140°, the Knee injury and Osteoarthritis Outcome Score was 88, and the visual analog scale pain score was 5/100.</p> Conclusions <p>Potentially correctable metabolic abnormalities may coexist with mechanical and biological risk factors in young patients with difficult nonunion. An integrated biological and mechanical strategy may achieve durable union and long-term functional recovery, although causal inference is limited in a single case report.</p>

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Atrophic tibial shaft nonunion in a young elite skier possibly associated with severe vitamin D deficiency and vitamin K insufficiency successfully treated with graft-free chipping and circular external fixation: a 10-year follow-up case report

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  • 发表日期：

    2026年8月5日

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  • Koji Nozaka,
  • Naohisa Miyakoshi

摘要

Background

Long-bone nonunion is multifactorial and may involve mechanical instability, local biological compromise, and potentially modifiable metabolic abnormalities. We report a rare case of atrophic tibial shaft nonunion in a young elite skier with severe vitamin D deficiency and elevated undercarboxylated osteocalcin, treated using an integrated biological and mechanical strategy.

Case presentation

A 28-year-old Japanese female elite skier sustained a high-energy skiing injury resulting in a Schatzker type VI tibial plateau fracture with an associated tibial shaft fracture. Initial treatment at another hospital consisted of plate fixation for the tibial plateau fracture and intramedullary nailing for the tibial shaft fracture. Painful atrophic tibial shaft nonunion persisted for 18 months, and she was referred to our institution. Radiographs showed 7° varus deformity, 3° anterior convexity, and a femorotibial angle of 180°. Metabolic evaluation revealed severe vitamin D deficiency, with serum 25-hydroxyvitamin D below the measurable range (< 7 ng/mL), and elevated undercarboxylated osteocalcin (11.2 ng/mL), suggesting vitamin K insufficiency in bone metabolism. Revision surgery consisted of implant removal, graft-free chipping of the tibial and fibular nonunion sites, acute correction using a Taylor Spatial Frame, olive-wire compression, and circular fixation allowing immediate postoperative weight-bearing. Postoperative alignment was corrected to 2° valgus, 7° recurvatum, and a femorotibial angle of 175°. Union was achieved, and the frame was removed at 5 months. The patient later underwent anterior cruciate ligament reconstruction for an unrelated sports injury and returned to competitive skiing within 1 year. At the 10-year follow-up, solid union was maintained, knee range of motion was 0°–140°, the Knee injury and Osteoarthritis Outcome Score was 88, and the visual analog scale pain score was 5/100.

Conclusions

Potentially correctable metabolic abnormalities may coexist with mechanical and biological risk factors in young patients with difficult nonunion. An integrated biological and mechanical strategy may achieve durable union and long-term functional recovery, although causal inference is limited in a single case report.