Symptomatic fibular non-union after hybrid lateral closing wedge high tibial osteotomy: a report of two cases

Abstract

Fibular osteotomy is an essential step in hybrid lateral closing wedge high tibial osteotomy (LCW-HTO), allowing adequate tibial correction in patients with varus malalignment. Although radiological fibular non-union following LCW-HTO is relatively common, it is predominantly asymptomatic and rarely affects clinical outcomes or requires further intervention. Consequently, fibular non-union is often considered a benign radiographic finding. We report two unusual cases of symptomatic fibular non-union following hybrid LCW-HTO. One patient developed non-union after an oblique mid-diaphyseal fibular osteotomy, while the other followed segmental fibular excision. Both patients presented more than one year postoperatively with persistent, localized lateral leg pain associated with a characteristic pricking sensation during weight bearing, despite satisfactory tibial osteotomy union and good knee function. Clinical examination revealed focal tenderness over the fibular site with no neurological deficits. Plain radiographs and CT confirmed fibular non-union in both cases. Given the duration of symptoms and lack of radiological union, surgical intervention was planned. Both patients underwent fibular plate fixation with autologous iliac crest bone grafting. Radiological union was achieved in both cases within 6 months, with complete resolution of pain and return to full function. This report highlights that, although fibular non-union after hybrid LCW-HTO is usually asymptomatic, a small subset of patients may develop persistent, clinically significant symptoms. Recognition of symptomatic fibular non-union is important, as timely surgical stabilization with bone grafting provides reliable union and excellent clinical outcomes.