{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,21]],"date-time":"2026-04-21T21:02:55Z","timestamp":1776805375927,"version":"3.51.2"},"reference-count":48,"publisher":"Elsevier BV","license":[{"start":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T00:00:00Z","timestamp":1777593600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/www.elsevier.com\/tdm\/userlicense\/1.0\/"},{"start":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T00:00:00Z","timestamp":1777593600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/www.elsevier.com\/legal\/tdmrep-license"}],"content-domain":{"domain":["clinicalkey.com","clinicalkey.com.au","clinicalkey.es","clinicalkey.fr","clinicalkey.jp","journal-cot.com","elsevier.com","sciencedirect.com"],"crossmark-restriction":true},"short-container-title":["Journal of Clinical Orthopaedics and Trauma"],"published-print":{"date-parts":[[2026,5]]},"DOI":"10.1016\/j.jcot.2026.103425","type":"journal-article","created":{"date-parts":[[2026,3,31]],"date-time":"2026-03-31T03:57:58Z","timestamp":1774929478000},"page":"103425","update-policy":"https:\/\/doi.org\/10.1016\/elsevier_cm_policy","source":"Crossref","is-referenced-by-count":0,"special_numbering":"C","title":["Understanding and treatment of aseptic femoral shaft nonunion: Biological and mechanical perspectives"],"prefix":"10.1016","volume":"76","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5205-4305","authenticated-orcid":false,"given":"Ashok S.","family":"Gavaskar","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"78","reference":[{"issue":"2","key":"10.1016\/j.jcot.2026.103425_bib1","first-page":"106","article-title":"Intramedullary nailing of the femur: reamed versus nonreamed","volume":"82","author":"Brumback","year":"2000","journal-title":"J Bone Joint Surg Am"},{"issue":"11","key":"10.1016\/j.jcot.2026.103425_bib2","first-page":"2093","article-title":"Randomized trial of reamed and unreamed intramedullary nailing of femoral shaft fractures","volume":"85","author":"Bhandari","year":"2003","journal-title":"J Bone Joint Surg Am"},{"issue":"2","key":"10.1016\/j.jcot.2026.103425_bib3","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1007\/s00264-017-3734-5","article-title":"Diaphyseal long bone nonunions - types, aetiology, economics, and treatment recommendations","volume":"42","author":"Rupp","year":"2018","journal-title":"Int Orthop"},{"issue":"2","key":"10.1016\/j.jcot.2026.103425_bib4","doi-asserted-by":"crossref","first-page":"186","DOI":"10.11138\/ccmbm\/2017.14.1.186","article-title":"Non-unions","volume":"14","author":"Calori","year":"2017","journal-title":"Clin Cases Miner Bone Metab"},{"issue":"12","key":"10.1016\/j.jcot.2026.103425_bib5","doi-asserted-by":"crossref","first-page":"1680","DOI":"10.1007\/s43465-024-01249-6","article-title":"Nonunion of Fractures: a review of epidemiology, diagnosis, and clinical features in recent literature","volume":"58","author":"Gharu","year":"2024","journal-title":"Indian J Orthop"},{"key":"10.1016\/j.jcot.2026.103425_bib6","series-title":"Skeletal Trauma: Basic Science, Management, and Reconstruction","first-page":"2481","article-title":"Nonunions: evaluation and treatment","author":"Brinker","year":"2009"},{"key":"10.1016\/j.jcot.2026.103425_bib7","series-title":"Pseudarthrosis: Pathophysiology, Biomechanics, Therapy, Results","author":"Weber","year":"1976"},{"issue":"3","key":"10.1016\/j.jcot.2026.103425_bib8","doi-asserted-by":"crossref","first-page":"593","DOI":"10.1016\/S0736-0266(01)00142-5","article-title":"Human atrophic fracture non-unions are not avascular","volume":"20","author":"Reed","year":"2002","journal-title":"J Orthop Res"},{"issue":"3","key":"10.1016\/j.jcot.2026.103425_bib9","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1038\/nrrheum.2012.1","article-title":"Fracture healing under healthy and inflammatory conditions","volume":"8","author":"Claes","year":"2012","journal-title":"Nat Rev Rheumatol"},{"issue":"4","key":"10.1016\/j.jcot.2026.103425_bib10","first-page":"795","article-title":"The risk factors of non-union after femoral shaft fracture fixation","volume":"48","author":"Mills","year":"2017","journal-title":"Injury"},{"issue":"7","key":"10.1016\/j.jcot.2026.103425_bib11","first-page":"444","article-title":"Risk factors for nonunion following intramedullary nailing of femoral shaft fractures","volume":"15","author":"Zlowodzki","year":"2001","journal-title":"J Orthop Trauma"},{"issue":"11","key":"10.1016\/j.jcot.2026.103425_bib12","doi-asserted-by":"crossref","first-page":"1356","DOI":"10.1016\/j.injury.2011.06.024","article-title":"Femoral shaft fractures treated with intramedullary nailing: the role of fracture type and mechanical stability on healing","volume":"42","author":"Papakostidis","year":"2011","journal-title":"Injury"},{"issue":"7","key":"10.1016\/j.jcot.2026.103425_bib13","first-page":"1763","article-title":"Fractures of the femoral shaft","volume":"91","author":"Ricci","year":"2009","journal-title":"J Bone Joint Surg Am"},{"issue":"2","key":"10.1016\/j.jcot.2026.103425_bib14","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1097\/00005131-200102000-00003","article-title":"Angular malalignment after intramedullary nailing of femoral shaft fractures","volume":"15","author":"Ricci","year":"2001","journal-title":"J Orthop Trauma"},{"issue":"10","key":"10.1016\/j.jcot.2026.103425_bib15","first-page":"684","article-title":"Alignment in the intramedullary nailing of femoral shaft fractures","volume":"22","author":"Gardner","year":"2008","journal-title":"J Orthop Trauma"},{"issue":"4","key":"10.1016\/j.jcot.2026.103425_bib16","doi-asserted-by":"crossref","first-page":"577","DOI":"10.1002\/jor.1100150414","article-title":"Influence of size and stability of the osteotomy gap on the success of fracture healing","volume":"15","author":"Claes","year":"1997","journal-title":"J Orthop Res"},{"issue":"3","key":"10.1016\/j.jcot.2026.103425_bib17","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1097\/BOT.0000000000001358","article-title":"Distal nail target and alignment of distal tibia fractures","volume":"33","author":"Brinkmann","year":"2019","journal-title":"J Orthop Trauma"},{"key":"10.1016\/j.jcot.2026.103425_bib18","first-page":"291","article-title":"The thermal effects of cortical bone reaming","volume":"266","author":"Whitelaw","year":"1991","journal-title":"Clin Orthop Relat Res"},{"issue":"Suppl 2","key":"10.1016\/j.jcot.2026.103425_bib19","doi-asserted-by":"crossref","first-page":"S3","DOI":"10.1016\/j.injury.2014.04.002","article-title":"Delayed union and nonunions: epidemiology, clinical issues, and financial aspects","volume":"45","author":"Hak","year":"2014","journal-title":"Injury"},{"issue":"7","key":"10.1016\/j.jcot.2026.103425_bib20","doi-asserted-by":"crossref","first-page":"980","DOI":"10.1016\/j.injury.2011.06.030","article-title":"Diagnostic and treatment modalities in nonunions of the femoral shaft: a review","volume":"43","author":"Gelalis","year":"2012","journal-title":"Injury"},{"key":"10.1016\/j.jcot.2026.103425_bib21","first-page":"175","article-title":"Physical and biological aspects of fracture healing with special reference to internal fixation","volume":"138","author":"Perren","year":"1979","journal-title":"Clin Orthop Relat Res"},{"issue":"7","key":"10.1016\/j.jcot.2026.103425_bib22","doi-asserted-by":"crossref","first-page":"884","DOI":"10.1302\/0301-620X.98B7.36061","article-title":"A unified theory of bone healing and nonunion: the bone-healing unit","volume":"98-B","author":"Elliott","year":"2016","journal-title":"Bone Jt J"},{"issue":"6","key":"10.1016\/j.jcot.2026.103425_bib23","doi-asserted-by":"crossref","first-page":"2259","DOI":"10.3390\/app14062259","article-title":"A review of the impacts of implant stiffness on fracture healing","volume":"14","author":"Mori","year":"2024","journal-title":"Appl Sci"},{"issue":"3","key":"10.1016\/j.jcot.2026.103425_bib24","doi-asserted-by":"crossref","first-page":"505","DOI":"10.1016\/j.injury.2017.08.040","article-title":"Fracture-related infection: a consensus on definition from an international expert group","volume":"49","author":"Metsemakers","year":"2018","journal-title":"Injury"},{"issue":"8","key":"10.1016\/j.jcot.2026.103425_bib25","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1097\/BOT.0b013e31814d4dc6","article-title":"Metabolic and endocrine abnormalities in patients with nonunions","volume":"21","author":"Brinker","year":"2007","journal-title":"J Orthop Trauma"},{"issue":"21","key":"10.1016\/j.jcot.2026.103425_bib26","doi-asserted-by":"crossref","first-page":"6553","DOI":"10.3390\/jcm13216553","article-title":"Nutritional indicators of bone nonunion: a systematic review","volume":"13","author":"Christianson","year":"2024","journal-title":"J Clin Med"},{"issue":"7","key":"10.1016\/j.jcot.2026.103425_bib27","doi-asserted-by":"crossref","first-page":"92","DOI":"10.5312\/wjo.v9.i7.92","article-title":"Systematic review of dynamization vs exchange nailing for delayed\/non-union femoral fractures","volume":"9","author":"Vaughn","year":"2018","journal-title":"World J Orthoped"},{"issue":"11","key":"10.1016\/j.jcot.2026.103425_bib28","doi-asserted-by":"crossref","DOI":"10.1016\/j.injury.2025.112748","article-title":"Nail dynamization for delayed union and nonunion in femur and tibia fractures following intramedullary nailing: a systematic review and meta-analysis","volume":"56","author":"Yu","year":"2025","journal-title":"Injury"},{"issue":"9","key":"10.1016\/j.jcot.2026.103425_bib29","doi-asserted-by":"crossref","first-page":"653","DOI":"10.1097\/BOT.0b013e3181a2a337","article-title":"The outcome of closed, intramedullary exchange nailing with reamed insertion in the treatment of femoral shaft nonunions","volume":"23","author":"Shroeder","year":"2009","journal-title":"J Orthop Trauma"},{"issue":"1","key":"10.1016\/j.jcot.2026.103425_bib30","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1007\/s00402-017-2802-z","article-title":"Exchange nailing with enhanced distal fixation is effective for the treatment of infraisthmal femoral nonunions","volume":"138","author":"Kim","year":"2018","journal-title":"Arch Orthop Trauma Surg"},{"issue":"2","key":"10.1016\/j.jcot.2026.103425_bib31","doi-asserted-by":"crossref","DOI":"10.1097\/OI9.0000000000000387","article-title":"High rate of complications with exchange nailing for femoral nonunions","volume":"8","author":"Averkamp","year":"2025","journal-title":"OTA Int"},{"key":"10.1016\/j.jcot.2026.103425_bib32","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1186\/s13018-014-0088-1","article-title":"Reamed intramedullary exchange nailing: treatment of choice of aseptic femoral shaft nonunion","volume":"9","author":"Hierholzer","year":"2014","journal-title":"J Orthop Surg Res"},{"issue":"2","key":"10.1016\/j.jcot.2026.103425_bib33","doi-asserted-by":"crossref","first-page":"89","DOI":"10.5152\/j.aott.2024.23163","article-title":"Biomechanical comparison of an intramedullary nail combined with a reconstruction plate versus a single nail in unstable femoral fracture models","volume":"58","author":"Zhang","year":"2024","journal-title":"Acta Orthop Traumatol Turcica"},{"issue":"6","key":"10.1016\/j.jcot.2026.103425_bib34","doi-asserted-by":"crossref","first-page":"1895","DOI":"10.1007\/s00068-020-01333-0","article-title":"Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing: a multicentre study","volume":"47","author":"Uliana","year":"2021","journal-title":"Eur J Trauma Emerg Surg"},{"issue":"4","key":"10.1016\/j.jcot.2026.103425_bib35","doi-asserted-by":"crossref","first-page":"242","DOI":"10.1016\/j.jor.2016.06.003","article-title":"Plate augmentation with retention of intramedullary nail is effective for resistant femoral shaft non-union","volume":"13","author":"Vaishya","year":"2016","journal-title":"J Orthop"},{"issue":"4","key":"10.1016\/j.jcot.2026.103425_bib36","doi-asserted-by":"crossref","first-page":"650","DOI":"10.3390\/jpm13040650","article-title":"Augmentative plating versus Exchange Intramedullary nailing for the treatment of aseptic non-unions of the femoral Shaft-A biomechanical Study in a SawboneTM model","volume":"13","author":"Walcher","year":"2023","journal-title":"J Personalized Med"},{"issue":"3","key":"10.1016\/j.jcot.2026.103425_bib37","doi-asserted-by":"crossref","first-page":"1259","DOI":"10.1007\/s00402-023-05183-4","article-title":"Comparing outcomes of plate augmentation, nail exchange, and nail exchange with plate augmentation in the treatment of atrophic femoral shaft nonunion after intramedullary nailing: a multicenter retrospective study","volume":"144","author":"Kook","year":"2024","journal-title":"Arch Orthop Trauma Surg"},{"issue":"3","key":"10.1016\/j.jcot.2026.103425_bib38","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1007\/s11751-018-0323-0","article-title":"Uniting the un-united: should established non-unions of femoral shaft fractures initially treated with IM nails be treated by plate augmentation instead of exchange IM nailing? A systematic review","volume":"13","author":"Medlock","year":"2018","journal-title":"Strategies Trauma Limb Reconstr"},{"issue":"Suppl 2","key":"10.1016\/j.jcot.2026.103425_bib39","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1016\/j.jcot.2016.02.013","article-title":"Management of complex femoral nonunion with monorail external fixator: a prospective study","volume":"7","author":"Agrawal","year":"2016","journal-title":"J Clin Orthop Trauma"},{"key":"10.1016\/j.jcot.2026.103425_bib40","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1097\/01.blo.0000159153.09508.97","article-title":"Treatment of femoral nonunions by using cyclic compression and distraction","volume":"436","author":"Inan","year":"2005","journal-title":"Clin Orthop Relat Res"},{"issue":"Suppl 4","key":"10.1016\/j.jcot.2026.103425_bib41","doi-asserted-by":"crossref","first-page":"S3","DOI":"10.1016\/S0020-1383(08)70003-2","article-title":"Fracture healing: the diamond concept","volume":"38","author":"Giannoudis","year":"2007","journal-title":"Injury"},{"issue":"Suppl 2","key":"10.1016\/j.jcot.2026.103425_bib42","doi-asserted-by":"crossref","first-page":"S78","DOI":"10.1016\/j.injury.2020.10.009","article-title":"The role of mechanical stimulation in the enhancement of bone healing","volume":"52","author":"Augat","year":"2021","journal-title":"Injury"},{"key":"10.1016\/j.jcot.2026.103425_bib43","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1097\/00003086-197209000-00011","article-title":"Muscle pedicle bone grafting of long bones by osteoperiosteal decortication","volume":"87","author":"Judet","year":"1972","journal-title":"Clin Orthop Relat Res"},{"issue":"2","key":"10.1016\/j.jcot.2026.103425_bib44","doi-asserted-by":"crossref","first-page":"286","DOI":"10.1016\/j.injury.2021.10.002","article-title":"RIA versus ilac crest bone graft harvesting: A metaanalysis and systematic review","volume":"53","author":"van de Wall","year":"2022","journal-title":"Injury"},{"issue":"Suppl 6","key":"10.1016\/j.jcot.2026.103425_bib45","first-page":"S108","article-title":"Smart implants in fracture care \u2013 only buzzword or real opportunity?","volume":"52","author":"Ernst","year":"2021","journal-title":"Injury"},{"issue":"1","key":"10.1016\/j.jcot.2026.103425_bib46","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1186\/s12891-025-08365-w","article-title":"Mesenchymal stem cells therapy for the treatment of non-union fractures: a systematic review and meta-analysis","volume":"26","author":"Cui","year":"2025","journal-title":"BMC Muscoskelet Disord"},{"issue":"7","key":"10.1016\/j.jcot.2026.103425_bib47","doi-asserted-by":"crossref","first-page":"1257","DOI":"10.1007\/s00590-018-2193-z","article-title":"Nanotechnology: the scope and potential applications in orthopedic surgery","volume":"28","author":"Gavaskar","year":"2018","journal-title":"Eur J Orthop Surg Traumatol"},{"key":"10.1016\/j.jcot.2026.103425_bib48","doi-asserted-by":"crossref","DOI":"10.5435\/JAAOSGlobal-D-24-00214","article-title":"A scoring system for predicting nonunion after intramedullary nailing of femoral shaft fractures","volume":"8","author":"Kraus","year":"2024","journal-title":"JAAOS Glob Res Rev"}],"container-title":["Journal of Clinical Orthopaedics and Trauma"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.elsevier.com\/content\/article\/PII:S0976566226000925?httpAccept=text\/xml","content-type":"text\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/api.elsevier.com\/content\/article\/PII:S0976566226000925?httpAccept=text\/plain","content-type":"text\/plain","content-version":"vor","intended-application":"text-mining"}],"deposited":{"date-parts":[[2026,4,21]],"date-time":"2026-04-21T20:21:46Z","timestamp":1776802906000},"score":1,"resource":{"primary":{"URL":"https:\/\/linkinghub.elsevier.com\/retrieve\/pii\/S0976566226000925"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5]]},"references-count":48,"alternative-id":["S0976566226000925"],"URL":"https:\/\/doi.org\/10.1016\/j.jcot.2026.103425","relation":{},"ISSN":["0976-5662"],"issn-type":[{"value":"0976-5662","type":"print"}],"subject":[],"published":{"date-parts":[[2026,5]]},"assertion":[{"value":"Elsevier","name":"publisher","label":"This article is maintained by"},{"value":"Understanding and treatment of aseptic femoral shaft nonunion: Biological and mechanical perspectives","name":"articletitle","label":"Article Title"},{"value":"Journal of Clinical Orthopaedics and Trauma","name":"journaltitle","label":"Journal Title"},{"value":"https:\/\/doi.org\/10.1016\/j.jcot.2026.103425","name":"articlelink","label":"CrossRef DOI link to publisher maintained version"},{"value":"article","name":"content_type","label":"Content Type"},{"value":"\u00a9 2026","name":"copyright","label":"Copyright"}],"article-number":"103425"}}