{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T18:48:27Z","timestamp":1770749307053,"version":"3.50.0"},"reference-count":32,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T00:00:00Z","timestamp":1761609600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T00:00:00Z","timestamp":1761609600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Eur J Trauma Emerg Surg"],"published-print":{"date-parts":[[2025,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>This study compared patient-reported functional outcomes, range of motion, and radiological alignment in antegrade (AN) versus retrograde nailing (RN) for midshaft femur fractures (AO\/OTA type 32).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A retrospective review of adult patients treated between January 1, 2001, and May 1, 2016, was conducted. Patients completed questionnaires and underwent physical exams to measure leg length, rotation, and hip\/knee range of motion. Final radiographs assessed union alignment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 162 patients with 173 fractures were included, with a median follow-up of 8.2 years. Of the 52 patients completing full follow-up, 8% showed rotational malalignment with a flexed hip, and 6% had\u2009&gt;\u200915\u00b0 malalignment with an extended hip. Knee flexion-extension range was slightly better in the AN group (130\u00b0 vs. 125\u00b0;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.019). Patients treated with AN also showed better results in the Lower Extremity Functional Scale (LKS) (83 vs. 61;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.041) and the SMFA dysfunction index (13 vs. 29;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.026) compared to RN.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>While both nailing techniques produced similar overall outcomes, AN demonstrated fewer complications, fewer rotational issues, and better patient-reported outcomes. Based on these findings, AN is preferred over RN for treating midshaft femoral fractures when technically feasible.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00068-025-02990-9","type":"journal-article","created":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T10:55:50Z","timestamp":1761648950000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Long-term outcome after middle third fractures of the femur shaft; a comparison between antegrade and retrograde nailing"],"prefix":"10.1007","volume":"51","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6361-3099","authenticated-orcid":false,"given":"J. Dani\u00ebl","family":"Cnossen","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2597-7948","authenticated-orcid":false,"given":"Esther M. M.","family":"Van Lieshout","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8448-5903","authenticated-orcid":false,"given":"Michael H. J.","family":"Verhofstad","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2025,10,28]]},"reference":[{"issue":"5","key":"2990_CR1","doi-asserted-by":"publisher","first-page":"423","DOI":"10.3109\/17453678609014762","volume":"57","author":"R Hedlund","year":"1986","unstructured":"Hedlund R, Lindgren U. Epidemiology of diaphyseal femoral fracture. Acta Orthop Scand. 1986;57(5):423\u20137.","journal-title":"Acta Orthop Scand"},{"issue":"3","key":"2990_CR2","doi-asserted-by":"publisher","first-page":"304","DOI":"10.1016\/j.injury.2008.07.017","volume":"40","author":"RJ Weiss","year":"2009","unstructured":"Weiss RJ, Montgomery SM, Al Dabbagh Z, Jansson KA. National data of 6409 Swedish inpatients with femoral shaft fractures: stable incidence between 1998 and 2004. Injury. 2009;40(3):304\u20138.","journal-title":"Injury"},{"key":"2990_CR3","unstructured":"Asplund CAMT. Midshaft fractures in adults: UpToDate; 2016 [Available from: http:\/\/www.uptodate.com\/contents\/midshaft-femur-fractures-in-adults"},{"issue":"4","key":"2990_CR4","doi-asserted-by":"publisher","first-page":"529","DOI":"10.2106\/00004623-198466040-00006","volume":"66","author":"RA Winquist","year":"1984","unstructured":"Winquist RA, Hansen ST Jr., Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. J Bone Joint Surg Am. 1984;66(4):529\u201339.","journal-title":"J Bone Joint Surg Am"},{"issue":"6","key":"2990_CR5","doi-asserted-by":"publisher","first-page":"1442","DOI":"10.1097\/TA.0b013e3182782696","volume":"73","author":"JA Harvin","year":"2012","unstructured":"Harvin JA, Harvin WH, Camp E, Caga-Anan Z, Burgess AR, Wade CE, et al. Early femur fracture fixation is associated with a reduction in pulmonary complications and hospital charges: a decade of experience with 1,376 diaphyseal femur fractures. J Trauma Acute Care Surg. 2012;73(6):1442\u20138. discussion 8\u20139.","journal-title":"J Trauma Acute Care Surg"},{"issue":"1","key":"2990_CR6","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1097\/BOT.0b013e31816073b6","volume":"22","author":"M Archdeacon","year":"2008","unstructured":"Archdeacon M, Ford KR, Wyrick J, Paterno MV, Hampton S, Ludwig MB, et al. A prospective functional outcome and motion analysis evaluation of the hip abductors after femur fracture and antegrade nailing. J Orthop Trauma. 2008;22(1):3\u20139.","journal-title":"J Orthop Trauma"},{"issue":"1","key":"2990_CR7","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1097\/BOT.0b013e31815f5357","volume":"22","author":"N Helmy","year":"2008","unstructured":"Helmy N, Jando VT, Lu T, Chan H, O\u2019Brien PJ. Muscle function and functional outcome following standard antegrade reamed intramedullary nailing of isolated femoral shaft fractures. J Orthop Trauma. 2008;22(1):10\u20135.","journal-title":"J Orthop Trauma"},{"issue":"Suppl 9","key":"2990_CR8","first-page":"S99","volume":"95","author":"S Juengteerapanich","year":"2012","unstructured":"Juengteerapanich S, Udomkiat P, Mahaisavariya B. Heterotopic ossification after closed femoral nailing. J Med Assoc Thai. 2012;95(Suppl 9):S99-103.","journal-title":"J Med Assoc Thai"},{"issue":"3","key":"2990_CR9","doi-asserted-by":"publisher","first-page":"161","DOI":"10.1097\/00005131-200103000-00003","volume":"15","author":"WM Ricci","year":"2001","unstructured":"Ricci WM, Bellabarba C, Evanoff B, Herscovici D, DiPasquale T, Sanders R. Retrograde versus antegrade nailing of femoral shaft fractures. J Orthop Trauma. 2001;15(3):161\u20139.","journal-title":"J Orthop Trauma"},{"issue":"11","key":"2990_CR10","doi-asserted-by":"publisher","first-page":"1337","DOI":"10.1016\/j.injury.2004.07.052","volume":"36","author":"CM Ansari Moein","year":"2005","unstructured":"Ansari Moein CM, Verhofstad MH, Bleys RL, van der Werken C. Soft tissue injury related to choice of entry point in antegrade femoral nailing: piriform fossa or greater trochanter tip. Injury. 2005;36(11):1337\u201342.","journal-title":"Injury"},{"issue":"7","key":"2990_CR11","doi-asserted-by":"publisher","first-page":"496","DOI":"10.1097\/00005131-200009000-00006","volume":"14","author":"RF Ostrum","year":"2000","unstructured":"Ostrum RF, Agarwal A, Lakatos R, Poka A. Prospective comparison of retrograde and antegrade femoral intramedullary nailing. J Orthop Trauma. 2000;14(7):496\u2013501.","journal-title":"J Orthop Trauma"},{"issue":"5","key":"2990_CR12","doi-asserted-by":"publisher","first-page":"652","DOI":"10.1302\/0301-620X.82B5.0820652","volume":"82","author":"P3rd Tornetta","year":"2000","unstructured":"Tornetta P3rd, Tiburzi D. Antegrade or retrograde reamed femoral nailing. A prospective, randomised trial. J Bone Joint Surg Br. 2000;82(5):652\u20134.","journal-title":"J Bone Joint Surg Br"},{"issue":"2","key":"2990_CR13","first-page":"219","volume":"76","author":"M El Moumni","year":"2010","unstructured":"El Moumni M, Schraven P, ten Duis HJ, Wendt K. Persistent knee complaints after retrograde unreamed nailing of femoral shaft fractures. Acta Orthop Belg. 2010;76(2):219\u201325.","journal-title":"Acta Orthop Belg"},{"issue":"2","key":"2990_CR14","doi-asserted-by":"publisher","first-page":"205","DOI":"10.1016\/j.injury.2008.06.022","volume":"40","author":"M el Moumni","year":"2009","unstructured":"el Moumni M, Leenhouts PA, ten Duis HJ, Wendt KW. The incidence of non-union following unreamed intramedullary nailing of femoral shaft fractures. Injury. 2009;40(2):205\u20138.","journal-title":"Injury"},{"issue":"2","key":"2990_CR15","doi-asserted-by":"publisher","first-page":"135","DOI":"10.1007\/s00068-007-6156-z","volume":"33","author":"CK Yu","year":"2007","unstructured":"Yu CK, Singh VA, Mariapan S, Chong ST. Antegrade versus retrograde locked intramedullary nailing for femoral fractures: which is better? Eur J Trauma Emerg Surg. 2007;33(2):135\u201340.","journal-title":"Eur J Trauma Emerg Surg"},{"issue":"9","key":"2990_CR16","doi-asserted-by":"publisher","first-page":"640","DOI":"10.1097\/BOT.0b013e3181a5ad33","volume":"23","author":"B Daglar","year":"2009","unstructured":"Daglar B, Gungor E, Delialioglu OM, Karakus D, Ersoz M, Tasbas BA, et al. Comparison of knee function after antegrade and retrograde intramedullary nailing for diaphyseal femoral fractures: results of isokinetic evaluation. J Orthop Trauma. 2009;23(9):640\u20134.","journal-title":"J Orthop Trauma"},{"issue":"7","key":"2990_CR17","doi-asserted-by":"publisher","first-page":"403","DOI":"10.1097\/00005131-200408000-00002","volume":"18","author":"RL Jaarsma","year":"2004","unstructured":"Jaarsma RL, Pakvis DF, Verdonschot N, Biert J, van Kampen A. Rotational malalignment after intramedullary nailing of femoral fractures. J Orthop Trauma. 2004;18(7):403\u20139.","journal-title":"J Orthop Trauma"},{"issue":"8","key":"2990_CR18","doi-asserted-by":"publisher","first-page":"1100","DOI":"10.1302\/0301-620X.86B8.15663","volume":"86","author":"RL Jaarsma","year":"2004","unstructured":"Jaarsma RL, van Kampen A. Rotational malalignment after fractures of the femur. J Bone Joint Surg Br. 2004;86(8):1100\u20134.","journal-title":"J Bone Joint Surg Br"},{"issue":"2","key":"2990_CR19","doi-asserted-by":"publisher","first-page":"195","DOI":"10.1016\/S0966-6362(01)00148-5","volume":"15","author":"B Gurney","year":"2002","unstructured":"Gurney B. Leg length discrepancy. Gait Posture. 2002;15(2):195\u2013206.","journal-title":"Gait Posture"},{"issue":"1","key":"2990_CR20","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1136\/ard.2002.001784","volume":"63","author":"LD Roorda","year":"2004","unstructured":"Roorda LD, Jones CA, Waltz M, Lankhorst GJ, Bouter LM, van der Eijken JW, et al. Satisfactory cross cultural equivalence of the Dutch WOMAC in patients with hip osteoarthritis waiting for arthroplasty. Ann Rheum Dis. 2004;63(1):36\u201342.","journal-title":"Ann Rheum Dis"},{"key":"2990_CR21","doi-asserted-by":"publisher","first-page":"43","DOI":"10.1097\/00003086-198509000-00007","volume":"198","author":"Y Tegner","year":"1985","unstructured":"Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;198:43\u20139.","journal-title":"Clin Orthop Relat Res"},{"key":"2990_CR22","doi-asserted-by":"publisher","first-page":"189","DOI":"10.1097\/00003086-200103000-00022","volume":"384","author":"P Soderman","year":"2001","unstructured":"Soderman P, Malchau H. Is the Harris hip score system useful to study the outcome of total hip replacement? Clin Orthop Relat Res. 2001;384:189\u201397.","journal-title":"Clin Orthop Relat Res"},{"issue":"4","key":"2990_CR23","doi-asserted-by":"publisher","first-page":"737","DOI":"10.2106\/00004623-196951040-00012","volume":"51","author":"WH Harris","year":"1969","unstructured":"Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51(4):737\u201355.","journal-title":"J Bone Joint Surg Am"},{"issue":"3","key":"2990_CR24","doi-asserted-by":"publisher","first-page":"917","DOI":"10.1007\/s11136-013-0529-z","volume":"23","author":"MA Van Son","year":"2014","unstructured":"Van Son MA, Den Oudsten BL, Roukema JA, Gosens T, Verhofstad MH, De Vries J. Psychometric properties of the Dutch short musculoskeletal function assessment (SMFA) questionnaire in patients with a fracture of the upper or lower extremity. Qual Life Res. 2014;23(3):917\u201326.","journal-title":"Qual Life Res"},{"issue":"2","key":"2990_CR25","doi-asserted-by":"publisher","first-page":"156","DOI":"10.1016\/j.injury.2010.06.024","volume":"42","author":"JR Phillips","year":"2011","unstructured":"Phillips JR, Trezies AJ, Davis TR. Long-term follow-up of femoral shaft fracture: relevance of malunion and malalignment for the development of knee arthritis. Injury. 2011;42(2):156\u201361.","journal-title":"Injury"},{"key":"2990_CR26","doi-asserted-by":"crossref","unstructured":"Kettelkamp DB, Hillberry BM, Murrish DE, Heck DA. Degenerative arthritis of the knee secondary to fracture malunion. Clin Orthop Relat Res. 1988;(234):159\u201369.","DOI":"10.1097\/00003086-198809000-00029"},{"issue":"5","key":"2990_CR27","first-page":"366","volume":"51","author":"DW Sanders","year":"2008","unstructured":"Sanders DW, MacLeod M, Charyk-Stewart T, Lydestad J, Domonkos A, Tieszer C. Functional outcome and persistent disability after isolated fracture of the femur. Can J Surg. 2008;51(5):366\u201370.","journal-title":"Can J Surg"},{"issue":"5","key":"2990_CR28","doi-asserted-by":"publisher","first-page":"799","DOI":"10.1302\/0301-620X.75B5.8376444","volume":"75","author":"M Braten","year":"1993","unstructured":"Braten M, Terjesen T, Rossvoll I. Torsional deformity after intramedullary nailing of femoral shaft fractures. Measurement of anteversion angles in 110 patients. J Bone Joint Surg Br. 1993;75(5):799\u2013803.","journal-title":"J Bone Joint Surg Br"},{"issue":"6","key":"2990_CR29","doi-asserted-by":"publisher","first-page":"823","DOI":"10.1007\/s00402-010-1245-6","volume":"131","author":"M Citak","year":"2011","unstructured":"Citak M, Suero EM, O\u2019Loughlin PF, Arvani M, Hufner T, Krettek C, et al. Femoral malrotation following intramedullary nailing in bilateral femoral shaft fractures. Arch Orthop Trauma Surg. 2011;131(6):823\u20137.","journal-title":"Arch Orthop Trauma Surg"},{"issue":"2","key":"2990_CR30","doi-asserted-by":"publisher","first-page":"375","DOI":"10.1097\/01.ta.0000230282.65606.81","volume":"61","author":"KH Salem","year":"2006","unstructured":"Salem KH, Maier D, Keppler P, Kinzl L, Gebhard F. Limb malalignment and functional outcome after antegrade versus retrograde intramedullary nailing in distal femoral fractures. J Trauma. 2006;61(2):375\u201381.","journal-title":"J Trauma"},{"issue":"7","key":"2990_CR31","doi-asserted-by":"publisher","first-page":"1154","DOI":"10.1016\/j.injury.2012.03.011","volume":"43","author":"M el Moumni","year":"2012","unstructured":"el Moumni M, Voogd EH, ten Duis HJ, Wendt KW. Long-term functional outcome following intramedullary nailing of femoral shaft fractures. Injury. 2012;43(7):1154\u20138.","journal-title":"Injury"},{"issue":"12","key":"2990_CR32","doi-asserted-by":"publisher","first-page":"3974","DOI":"10.1007\/s11999-013-3058-8","volume":"471","author":"PJ Dougherty","year":"2013","unstructured":"Dougherty PJ, Gherebeh P, Zekaj M, Sethi S, Oliphant B, Vaidya R. Retrograde versus antegrade intramedullary nailing of gunshot diaphyseal femur fractures. Clin Orthop Relat Res. 2013;471(12):3974\u201380.","journal-title":"Clin Orthop Relat Res"}],"container-title":["European Journal of Trauma and Emergency Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00068-025-02990-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00068-025-02990-9","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00068-025-02990-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T11:04:31Z","timestamp":1770721471000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00068-025-02990-9"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,28]]},"references-count":32,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2025,12]]}},"alternative-id":["2990"],"URL":"https:\/\/doi.org\/10.1007\/s00068-025-02990-9","relation":{},"ISSN":["1863-9933","1863-9941"],"issn-type":[{"value":"1863-9933","type":"print"},{"value":"1863-9941","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,28]]},"assertion":[{"value":"6 June 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"20 September 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"28 October 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The local Medical Research Ethics Committee exempted this study (ref. no. MEC-2016-348).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}},{"value":"all patients who are included in this study signed informed consent.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Informed consent"}},{"value":"All authors declare that they has have no conflict of interests or any competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"The authors declare no competing interests.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}},{"value":"During the preparation of this work the author(s) used no generative AI in the writing of this article.","order":6,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declaration of generative AI in scientific writing"}}],"article-number":"305"}}