{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,26]],"date-time":"2026-01-26T17:21:36Z","timestamp":1769448096786,"version":"3.49.0"},"reference-count":22,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,1,26]],"date-time":"2026-01-26T00:00:00Z","timestamp":1769385600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Surg."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The relationship between fragment characteristics and nonunion risk in comminuted femoral shaft fractures remains controversial. This study aimed to investigate the relationship between radiographic fragment features and fracture union outcomes to assist clinical assessment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Patients and methods<\/jats:title>\n                    <jats:p>A retrospective analysis was conducted on 91 femoral shaft fractures from 89 patients. Patient demographics, injury characteristics, and radiographic parameters\u2014including fragment size, displacement, gap area, nail-to-canal diameter ratio, and ALR (gap area\/major fragment length)\u2014were analyzed. Univariate and multivariate logistic regression were used to identify independent risk factors for nonunion.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The overall nonunion rate was 16.5% (15\/91). Univariate analysis revealed that a larger gap area (OR\u2009=\u20091.004,\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&amp;lt;\u20090.001) and a lower distal nail-to-canal diameter ratio (OR\u2009=\u20090.013,\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.023) were associated with nonunion. The novel ALR parameter demonstrated a strong association with nonunion (OR\u2009=\u20092.349,\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&amp;lt;\u20090.001). In multivariate analysis, ALR remained an independent predictor (OR\u2009=\u20092.304,\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&amp;lt;\u20090.001), while traditional factors like fragment size, displacement, and the nail-to-canal ratio were not significantly associated.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Traditional radiographic measures such as fragment length, width, Nail-to-canal ratio and absolute displacement did not show a significant association with healing outcome in our cohort. While the ALR is a significant predictor of nonunion in comminuted femoral shaft fractures, may assist in the early identification of cases at higher risk for nonunion, which could inform clinical vigilance regarding the potential need for more intensive management strategies.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fsurg.2026.1732494","type":"journal-article","created":{"date-parts":[[2026,1,26]],"date-time":"2026-01-26T07:10:54Z","timestamp":1769411454000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Area-to-Length Ratio: a significant predictor of nonunion following intramedullary nailing of comminuted femoral shaft fractures"],"prefix":"10.3389","volume":"13","author":[{"given":"Yi","family":"Shi","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wei","family":"Jiang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anquan","family":"Wang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xingyi","family":"Hua","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2026,1,26]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"296","DOI":"10.5435\/00124635-200905000-00004","article-title":"Intramedullary nailing of femoral shaft fractures: current concepts","volume":"17","author":"Ricci","year":"2009","journal-title":"J Am Acad Orthop Surg"},{"key":"B2","doi-asserted-by":"publisher","first-page":"1389","DOI":"10.1097\/TA.0b013e318182afd0","article-title":"Risk factors for femoral nonunion after femoral shaft fracture","volume":"67","author":"Taitsman","year":"2009","journal-title":"J Trauma"},{"key":"B3","doi-asserted-by":"publisher","first-page":"175","DOI":"10.1016\/j.otsr.2015.11.014","article-title":"Effects of third fragment size and displacement on non-union of femoral shaft fractures after locking for intramedullary nailing","volume":"102","author":"Lee","year":"2016","journal-title":"Orthop Traumatol Surg Res"},{"key":"B4","doi-asserted-by":"publisher","first-page":"193","DOI":"10.1007\/s00264-018-4214-2","article-title":"The impact of the third fragment features on the healing of femoral shaft fractures managed with intramedullary nailing: a radiological study","volume":"43","author":"Vicenti","year":"2019","journal-title":"Int Orthop"},{"key":"B5","doi-asserted-by":"publisher","first-page":"380","DOI":"10.1186\/s13018-022-03275-2","article-title":"Effect of the degree of displacement of the third fragment on healing of femoral shaft fracture treated by intramedullary nailing","volume":"17","author":"Yang","year":"2022","journal-title":"J Orthop Surg Res"},{"key":"B6","doi-asserted-by":"publisher","first-page":"738","DOI":"10.1016\/j.injury.2022.12.024","article-title":"Butterfly fragments in diaphyseal tibial fractures heal unpredictably: should we be adopting other strategies for these high risk fractures?","volume":"54","author":"Myhre","year":"2023","journal-title":"Injury"},{"key":"B7","doi-asserted-by":"publisher","first-page":"401","DOI":"10.1007\/s00402-025-06020-6","article-title":"Wedge fragments: no significant impact on bone healing in femoral shaft fractures treated with intramedullary nailing","volume":"145","author":"Yoon","year":"2025","journal-title":"Arch Orthop Trauma Surg"},{"key":"B8","doi-asserted-by":"publisher","first-page":"1663","DOI":"10.1111\/os.13372","article-title":"The butterfly fragment in wedge-shaped femoral shaft fracture: comparison of two different surgical methods","volume":"14","author":"Tsai","year":"2022","journal-title":"Orthop Surg"},{"key":"B9","doi-asserted-by":"publisher","first-page":"3664","DOI":"10.3390\/jcm11133664","article-title":"Perioperative radiographic predictors of non-union in infra-isthmal femoral shaft fractures after antegrade intramedullary nailing: a case-control study","volume":"11","author":"Hung","year":"2022","journal-title":"J Clin Med"},{"key":"B10","doi-asserted-by":"publisher","first-page":"826","DOI":"10.1186\/s12891-022-05781-0","article-title":"Does nail size or difference between canal and nail diameter influence likelihood of union or time to union of femoral shaft fractures treated with intramedullary nailing? 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