Background <p>Limb salvage in Gustilo IIIB open tibial fractures is particularly challenging in patients with chronic kidney disease undergoing hemodialysis, owing to increased susceptibility to infection, impaired bone healing, and vascular fragility. When microsurgical reconstruction fails, treatment options become extremely limited, particularly in cases with compromised vascularity such as single-vessel limbs. Acute shortening and gradual lengthening (ASGL) using the Ilizarov method represents a vascular-independent reconstructive strategy.</p> Case presentation <p>A 65-year-old man undergoing hemodialysis sustained a Gustilo IIIB open tibial fracture with a large soft tissue defect. Initial management at a referring hospital included debridement, external fixation, and free latissimus dorsi flap coverage; however, flap necrosis occurred. The patient was transferred to our institution. Given the presence of a single posterior tibial artery and the high risk of repeated microsurgical failure, further flap reconstruction was not attempted.</p> <p>Acute shortening of 75 mm was performed to enable soft tissue coverage using local muscles; dead space was reduced, and the shortened segment was subsequently covered with local muscle tissue.</p> <p>Subsequent gradual lengthening using the Ilizarov method (ASGL) was performed. Bone union and limb alignment were achieved, and the external fixator was removed at 17 months. At 8-year follow-up, the patient was pain-free and had returned to agricultural work.</p> Conclusions <p>ASGL may represent an effective vascular-independent salvage strategy in complex limb-threatening conditions after failed microsurgical reconstruction, particularly when further microsurgical procedures are not feasible.</p>