{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T15:22:51Z","timestamp":1787930571188,"version":"build-2784847793"},"reference-count":31,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T00:00:00Z","timestamp":1787875200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T00:00:00Z","timestamp":1787875200000},"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"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>This study investigated the rate and degree of deformity in femoral diaphyseal nonunion using preoperative bilateral CT-scans.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A retrospective cohort study was conducted at a single Level 1 trauma center. Patients aged\u2009&gt;\u200918 years who underwent operative treatment for femoral diaphyseal nonunion between 2015 and 2025 and had preoperative bilateral femur CT-scans were included. Axial, sagittal, coronal, and length differences between the femoral nonunion and the contralateral healthy femur were measured. Torsional deformity\u2009\u2265\u200915\u00b0 and length discrepancy\u2009\u2265\u200920\u00a0mm were considered clinically relevant. Thresholds of \u2265\u20095\u00b0 and \u2265\u200910\u00b0 were used to identify outliers in coronal and sagittal plane deformity, respectively.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Thirty-two patients met the inclusion criteria (median age 57 years, 63% male). Torsional deformity\u2009\u2265\u200915\u00b0 was present in 10 patients (31%), including internal rotation in 4 (13%) and external rotation in 6 (19%). Sagittal plane deformity\u2009\u2265\u200910\u00b0 was observed in 5 patients (16%), with apex anterior angulation in 1 (3%) and apex posterior angulation in 4 (13%). Mean sagittal plane angulation was 9.7\u00b0 \u00b1 6.7\u00b0 in the affected limb and 12.5\u00b0 \u00b1 2.6\u00b0 in the unaffected limb (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.017). Coronal plane deformity\u2009\u2265\u20095\u00b0 was present in 10 patients (31%), including varus in 8 (25%) and valgus in 2 (6%). Mean coronal angulation was 5.3\u00b0 \u00b1 6.0\u00b0 in the affected limb and 3.3\u00b0 \u00b1 2.5\u00b0 in the unaffected limb (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.099). Mean femoral length was 439\u2009\u00b1\u200931\u00a0mm in the affected limb and 445\u2009\u00b1\u200928\u00a0mm in the unaffected limb (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.015), with a length discrepancy\u2009\u2265\u200920\u00a0mm in 5 patients (16%).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Clinically relevant torsional deformity was present in one in three patients undergoing femoral shaft nonunion surgery, while femoral length discrepancy\u2009\u2265\u200920\u00a0mm occurred in one in six. A small but significant decrease in apex anterior angulation was observed, and most coronal plane outliers were in varus. These findings underline the importance of recognizing deformity in femoral nonunion.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00068-026-03314-1","type":"journal-article","created":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T14:43:14Z","timestamp":1787928194000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["What is the rate and degree of deformity in femoral diaphyseal nonunion? A CT-based retrospective cohort study"],"prefix":"10.1007","volume":"52","author":[{"given":"Joep","family":"Nabben","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert K.","family":"Wagner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Floor","family":"Groepenhoff","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tim A.","family":"Verwest","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yoram","family":"Bont","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Kloen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stein J.","family":"Janssen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,8,28]]},"reference":[{"key":"3314_CR1","doi-asserted-by":"publisher","unstructured":"Bianco Prevot L, et al. What is the best treatment of the femoral shaft nonunion after intramedullary nailing? A Syst Rev Life (Basel). 2023;13(7). https:\/\/doi.org\/10.3390\/life13071508.","DOI":"10.3390\/life13071508"},{"issue":"10","key":"3314_CR2","doi-asserted-by":"publisher","first-page":"512","DOI":"10.1302\/2046-3758.510.BJR-2016-0138","volume":"5","author":"L Mills","year":"2016","unstructured":"Mills L, et al. The multifactorial aetiology of fracture nonunion and the importance of searching for latent infection. Bone Joint Res. 2016;5(10):512\u20139. https:\/\/doi.org\/10.1302\/2046-3758.510.BJR-2016-0138.","journal-title":"Bone Joint Res"},{"key":"3314_CR3","doi-asserted-by":"publisher","first-page":"88","DOI":"10.1186\/s13018-014-0088-1","volume":"9","author":"C Hierholzer","year":"2014","unstructured":"Hierholzer C, et al. Reamed intramedullary exchange nailing: treatment of choice of aseptic femoral shaft nonunion. J Orthop Surg Res. 2014;9:88. https:\/\/doi.org\/10.1186\/s13018-014-0088-1.","journal-title":"J Orthop Surg Res"},{"issue":"3","key":"3314_CR4","doi-asserted-by":"publisher","first-page":"215","DOI":"10.1016\/j.ocl.2021.03.008","volume":"52","author":"M Sullivan","year":"2021","unstructured":"Sullivan M, Bonilla K, Donegan D. Malrotation of Long Bones. Orthop Clin North Am. 2021;52(3):215\u201329. https:\/\/doi.org\/10.1016\/j.ocl.2021.03.008.","journal-title":"Orthop Clin North Am"},{"issue":"2","key":"3314_CR5","first-page":"159","volume":"72","author":"JT Riehl","year":"2014","unstructured":"Riehl JT, et al. Intramedullary nailing of subtrochanteric fractures\u2013does malreduction matter? Bull Hosp Jt Dis (2013). 2014;72(2):159\u201363.","journal-title":"Bull Hosp Jt Dis (2013)"},{"key":"3314_CR6","doi-asserted-by":"publisher","unstructured":"Megas P. Classification of non-union. Injury, 2005. 36 Suppl 4: pp. S30-7. https:\/\/doi.org\/10.1016\/j.injury.2005.10.008.","DOI":"10.1016\/j.injury.2005.10.008"},{"key":"3314_CR7","doi-asserted-by":"publisher","first-page":"64","DOI":"10.1016\/j.jor.2023.10.029","volume":"46","author":"GS Kainth","year":"2023","unstructured":"Kainth GS, et al. Varus mal-alignment and residual displacement are associated with delayed union in subtrochanteric femur fracture- A retrospective observational study. J Orthop. 2023;46:64\u20139. https:\/\/doi.org\/10.1016\/j.jor.2023.10.029.","journal-title":"J Orthop"},{"key":"3314_CR8","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1007\/978-3-642-56330-0_2","volume-title":"Practice of Intramedullary Locked Nails: Scientific Basis and Standard Techniques Recommended by Association Internationale pour I\u2019Ost\u00e9osynth\u00e8se Dynamique (AIOD)","author":"F Biggi","year":"2002","unstructured":"Biggi F. The Biology of Fracture Healing as Related to Intramedullary Locked Nailing. In: Kempf I, et al. editors. Practice of Intramedullary Locked Nails: Scientific Basis and Standard Techniques Recommended by Association Internationale pour I\u2019Ost\u00e9osynth\u00e8se Dynamique (AIOD). Berlin Heidelberg: Berlin, Heidelberg: Springer; 2002. pp. 5\u201310."},{"key":"3314_CR9","doi-asserted-by":"publisher","DOI":"10.1007\/978-3-642-68538-5","volume-title":"A Computer Tomography of Neck,Chest,Spine and Limbs.Atlas of Pathologic Computer Tomography","author":"L Jeanmart","year":"1983","unstructured":"Jeanmart L, Wackenheim BA. A Computer Tomography of Neck,Chest,Spine and Limbs.Atlas of Pathologic Computer Tomography. Volume 3. New York, NY: Springer-; 1983."},{"issue":"3","key":"3314_CR10","doi-asserted-by":"publisher","first-page":"373","DOI":"10.1111\/anae.14569","volume":"74","author":"D Mayhew","year":"2019","unstructured":"Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status - historical perspectives and modern developments. Anaesthesia. 2019;74(3):373\u20139. https:\/\/doi.org\/10.1111\/anae.14569.","journal-title":"Anaesthesia"},{"key":"3314_CR11","unstructured":"Peter V, Giannoudis HCP, Sch\u00fctz M. AO surgery reference. 2018 12-30-2025]; Available from: https:\/\/surgeryreference.aofoundation.org\/orthopedic-trauma\/adult-trauma\/femoral-shaft."},{"key":"3314_CR12","doi-asserted-by":"publisher","DOI":"10.1097\/BOT.0000000000001063","author":"EG Meinberg","year":"2018","unstructured":"Meinberg EG, et al. Fracture and dislocation classification compendium-2018. J Orthop Trauma. 2018. https:\/\/doi.org\/10.1097\/BOT.0000000000001063. 32 Suppl 1: pS1-S170."},{"issue":"3","key":"3314_CR13","doi-asserted-by":"publisher","first-page":"505","DOI":"10.1016\/j.injury.2017.08.040","volume":"49","author":"WJ Metsemakers","year":"2018","unstructured":"Metsemakers WJ, et al. Fracture-related infection: A consensus on definition from an international expert group. Injury. 2018;49(3):505\u201310. https:\/\/doi.org\/10.1016\/j.injury.2017.08.040.","journal-title":"Injury"},{"issue":"6","key":"3314_CR14","doi-asserted-by":"publisher","first-page":"487","DOI":"10.1302\/2058-5241.6.210015","volume":"6","author":"N Marques Luis","year":"2021","unstructured":"Marques Luis N, Varatojo R. Radiological assessment of lower limb alignment. EFORT Open Rev. 2021;6(6):487\u201394. https:\/\/doi.org\/10.1302\/2058-5241.6.210015.","journal-title":"EFORT Open Rev"},{"issue":"12","key":"3314_CR15","doi-asserted-by":"publisher","first-page":"1248","DOI":"10.1016\/j.injury.2002.10.001","volume":"35","author":"BC Navadgi","year":"2004","unstructured":"Navadgi BC, et al. A corrective osteotomy for post-traumatic malrotation and shortening of the femur. Injury. 2004;35(12):1248\u201354. https:\/\/doi.org\/10.1016\/j.injury.2002.10.001.","journal-title":"Injury"},{"issue":"5","key":"3314_CR16","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. https:\/\/doi.org\/10.1302\/0301-620X.75B5.8376444.","journal-title":"J Bone Joint Surg Br"},{"issue":"1","key":"3314_CR17","doi-asserted-by":"publisher","first-page":"127","DOI":"10.1186\/s13018-017-0626-8","volume":"12","author":"Z Bao","year":"2017","unstructured":"Bao Z, et al. The assessment of femoral shaft morphology in the sagittal plane in Chinese patients with osteoarthritis-a radiographic analysis. J Orthop Surg Res. 2017;12(1):127. https:\/\/doi.org\/10.1186\/s13018-017-0626-8.","journal-title":"J Orthop Surg Res"},{"issue":"11","key":"3314_CR18","doi-asserted-by":"publisher","first-page":"1515","DOI":"10.1007\/s00402-017-2764-1","volume":"137","author":"JW Kim","year":"2017","unstructured":"Kim JW, et al. Surgical outcomes of intramedullary nailing for diaphyseal atypical femur fractures: is it safe to modify a nail entry in bowed femur? Arch Orthop Trauma Surg. 2017;137(11):1515\u201322. https:\/\/doi.org\/10.1007\/s00402-017-2764-1.","journal-title":"Arch Orthop Trauma Surg"},{"issue":"9","key":"3314_CR19","doi-asserted-by":"publisher","first-page":"1227","DOI":"10.1007\/s00402-016-2519-4","volume":"136","author":"Y Akamatsu","year":"2016","unstructured":"Akamatsu Y, et al. Femoral shaft bowing in the coronal and sagittal planes on reconstructed computed tomography in women with medial compartment knee osteoarthritis: a comparison with radiograph and its predictive factors. Arch Orthop Trauma Surg. 2016;136(9):1227\u201332. https:\/\/doi.org\/10.1007\/s00402-016-2519-4.","journal-title":"Arch Orthop Trauma Surg"},{"issue":"6","key":"3314_CR20","doi-asserted-by":"publisher","first-page":"861","DOI":"10.1016\/j.arth.2008.05.025","volume":"24","author":"AB Mullaji","year":"2009","unstructured":"Mullaji AB, Marawar SV, Mittal V. A comparison of coronal plane axial femoral relationships in Asian patients with varus osteoarthritic knees and healthy knees. J Arthroplasty. 2009;24(6):861\u20137. https:\/\/doi.org\/10.1016\/j.arth.2008.05.025.","journal-title":"J Arthroplasty"},{"issue":"3","key":"3314_CR21","doi-asserted-by":"publisher","first-page":"345","DOI":"10.1302\/0301-620X.93B3.25990","volume":"93","author":"TW Huang","year":"2011","unstructured":"Huang TW, et al. Total knee replacement in patients with significant femoral bowing in the coronal plane: a comparison of conventional and computer-assisted surgery in an Asian population. J Bone Joint Surg Br. 2011;93(3):345\u201350. https:\/\/doi.org\/10.1302\/0301-620X.93B3.25990.","journal-title":"J Bone Joint Surg Br"},{"issue":"12","key":"3314_CR22","doi-asserted-by":"publisher","first-page":"2910","DOI":"10.1007\/s11999-008-0524-9","volume":"466","author":"S Sabharwal","year":"2008","unstructured":"Sabharwal S, Kumar A. Methods for assessing leg length discrepancy. Clin Orthop Relat Res. 2008;466(12):2910\u201322. https:\/\/doi.org\/10.1007\/s11999-008-0524-9.","journal-title":"Clin Orthop Relat Res"},{"key":"3314_CR23","doi-asserted-by":"publisher","DOI":"10.1097\/BPO.0000000000001396","author":"JE Gordon","year":"2019","unstructured":"Gordon JE, Davis LE. Leg Length Discrepancy: The Natural History (And What Do We Really Know). J Pediatr Orthop. 2019;39(1):S10\u20133. https:\/\/doi.org\/10.1097\/BPO.0000000000001396. Issue 6, Supplement 1 Suppl."},{"key":"3314_CR24","doi-asserted-by":"publisher","unstructured":"Koo TK, Li MY. A Guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med. 2016;15(2). 155\u2009\u2013\u200963. https:\/\/doi.org\/10.1016\/j.jcm.2016.02.012","DOI":"10.1016\/j.jcm.2016.02.012"},{"issue":"7","key":"3314_CR25","doi-asserted-by":"publisher","first-page":"403","DOI":"10.1097\/00005131-200408000-00002","volume":"18","author":"RL Jaarsma","year":"2004","unstructured":"Jaarsma RL, et al. Rotational malalignment after intramedullary nailing of femoral fractures. J Orthop Trauma. 2004;18(7):403\u20139. https:\/\/doi.org\/10.1097\/00005131-200408000-00002.","journal-title":"J Orthop Trauma"},{"issue":"5","key":"3314_CR26","first-page":"418","volume":"11","author":"MM Mansouri-Tehrani","year":"2021","unstructured":"Mansouri-Tehrani MM, et al. Evaluation of femoral malrotation after intramedullary nailing. Int J Burns Trauma. 2021;11(5):418\u201323.","journal-title":"Int J Burns Trauma"},{"issue":"11","key":"3314_CR27","doi-asserted-by":"publisher","first-page":"583","DOI":"10.1097\/BOT.0000000000003048","volume":"39","author":"ML Anderson","year":"2025","unstructured":"Anderson ML, et al. Does Femoral Rotation More Closely Mirror the Contralateral Side or a Population Mean of 15 Degrees of Anteversion? A Radiologic Study of 219 Healthy Patients. J Orthop Trauma. 2025;39(11):583\u20139. https:\/\/doi.org\/10.1097\/BOT.0000000000003048.","journal-title":"J Orthop Trauma"},{"issue":"3","key":"3314_CR28","doi-asserted-by":"publisher","first-page":"e96","DOI":"10.1097\/BOT.0000000000001648","volume":"34","author":"LS Marchand","year":"2020","unstructured":"Marchand LS, et al. Assessing Femoral Rotation: A Survey Comparison of Techniques. J Orthop Trauma. 2020;34(3):e96\u2013101. https:\/\/doi.org\/10.1097\/BOT.0000000000001648.","journal-title":"J Orthop Trauma"},{"issue":"5","key":"3314_CR29","doi-asserted-by":"publisher","first-page":"279","DOI":"10.1097\/BOT.0000000000002790","volume":"38","author":"DV Ivanov","year":"2024","unstructured":"Ivanov DV, et al. Evaluation of Intraoperative Fluoroscopic Techniques to Estimate Femoral Rotation: A Cadaveric Study. J Orthop Trauma. 2024;38(5):279\u201384. https:\/\/doi.org\/10.1097\/BOT.0000000000002790.","journal-title":"J Orthop Trauma"},{"key":"3314_CR30","doi-asserted-by":"publisher","DOI":"10.1097\/BOT.0000000000003001","author":"RK Wagner","year":"2025","unstructured":"Wagner RK, et al. Risk Factors for Nonunion After Lateral Locked Plating of Periprosthetic Distal Femur Fractures. J Orthop Trauma. 2025. https:\/\/doi.org\/10.1097\/BOT.0000000000003001.","journal-title":"J Orthop Trauma"},{"issue":"6","key":"3314_CR31","doi-asserted-by":"publisher","first-page":"769","DOI":"10.1007\/s00402-019-03131-9","volume":"139","author":"D Krappinger","year":"2019","unstructured":"Krappinger D, et al. Risk factors for nonunion after intramedullary nailing of subtrochanteric femoral fractures. Arch Orthop Trauma Surg. 2019;139(6):769\u201377. https:\/\/doi.org\/10.1007\/s00402-019-03131-9.","journal-title":"Arch Orthop Trauma Surg"}],"container-title":["European Journal of Trauma and Emergency Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00068-026-03314-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00068-026-03314-1","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00068-026-03314-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T14:43:16Z","timestamp":1787928196000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00068-026-03314-1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,28]]},"references-count":31,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["3314"],"URL":"https:\/\/doi.org\/10.1007\/s00068-026-03314-1","relation":{"references":[{"id-type":"doi","id":"10.1097\/BOT.0000000000001063","asserted-by":"subject"},{"id-type":"doi","id":"10.1097\/BPO.0000000000001396","asserted-by":"subject"}]},"ISSN":["1863-9941"],"issn-type":[{"value":"1863-9941","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,28]]},"assertion":[{"value":"6 June 2026","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"24 August 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"28 August 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The study was reviewed by the Medical Ethics Review Committee Amsterdam UMC (METC Amsterdam UMC), location AMC, which confirmed that the study was not subject to the Dutch Medical Research Involving Human Subjects Act (WMO) (reference number: 2024.0225).","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":2,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"272"}}