Many attempts to use the medullary cavity of long bones for fracture fixation had been made over the past 500 years starting with Aztecs (16th century), Dieffenbach (1846), Bircher (1887), Gluck (1890), Senn (1893), Nicolaysen (1897), Lambotte (1907), Hey Groves (1910), Schöne (1913), Hoglund (1917), Rush (1936), and many others. However, none of these pioneers succeeded in an improved treatment of “one of the most difficult problems of osteosynthesis … —the diaphyseal fracture of the femur” to quote Soeur (1946). It was Gerhard Küntscher who paved the way for an improved outcome in the treatment of these fractures 75 years ago, innovating both the implant and the surgical technique. His work was the true progenitor of the intramedullary nail (IMN) as we know it today. But make your own judgment based on the first article in this JOT supplement. Despite widespread initial concerns, the technique quickly gained attention during World War II and spread throughout Europe due to its “relative ease of management of these severe fractures–both on the part of the patient as well as on that of the attending surgeon,” “sometimes known as medullary nail euphoria” (Schneider 1968). In 1942, 20 European surgeons from Germany, Austria, France, and Italy had already adopted the method; the number increased to 60 investigators in 1944, including Häbler, Maatz, Böhler, and Soeur, all of whom published on the topic in the 1940s. The United States learned about this technique in March of 1945, when Time magazine published an article entitled “Amazing Thighbone,” describing an American soldier treated with a Küntscher nail by German doctors for a fracture of his femur. US surgeons called the nail technique “a daring operation” and wondered how their German colleagues inserted it without dangerously injuring the medullary blood supply and without introducing infection. Finally, the reaction in the United States almost duplicated what happened earlier in Europe: After initial skepticism, the new treatment was quickly adopted and attempts were made by Hansen/Street (1945), Lottes (1946), MacAusland (1947), Livingston (1950), and Stryker (1950) to enhance the control of rotational forces and to expand indications of the IMN. Unfortunately, the rapid dissemination of the method in combination with a lack of training and education of surgeons, as well as a lack of quality implant stainless steel negatively impacted clinical outcomes, which were addressed in critical reviews from surgical authorities such as Watson-Jones and Böhler. Fortunately, with attention paid to basic principles and the availability of new enabling technologies, the method not only survived in the hands of well-trained surgeons, but also numerous improvements were made in the next decades. In the 1960s, image intensifiers became clinically available. This advancement significantly reduced radiation exposure and the risk of severe burns of surgeon and patient. The first ones to adopt were Küntscher and his “Detensing” nail, as well as Huckstep and his “Kampala” nail in 1968. It seems that also Huckstep first used an IMN made of titanium alloy. As a result, the era of modern locking nails began, offering additional strength and torsional control of the fracture and extending the indications to more complex comminuted fractures. The renewed interest in the procedure resulted in a variety of locking nails on the market, that is, Klemm/Schellmann (1972), Grosse/Kempf (1976), AO (1987), and Russell/Taylor (1992). Closed, reamed, antegrade intramedullary nailing was established as a standard care for femoral shaft fractures (Sanders 1993). So, the second article in this supplement reviews what had been achieved by 1990. Based on the great success of intramedullary nailing in shaft fractures, the 2 main drivers for innovation during the 1990s and 2000s were (1) to extend the indications to extreme proximal and distal femur and tibia fractures and (2) to go beyond pure fracture fixation to improve clinical outcome in terms of, for example, fracture alignment, pain, and range of motion. The retrograde approach as highlighted in the third article covered both of the above objectives, and an entirely new IMN family established in the subsequent years. In his 1940 article, Gerhard Küntscher also reports the use of a “double nail” to treat combined per- and subtrochanteric fractures. After Zickel in New York presented his IMN (1967) for the same indication, the Gamma Nail in 1989 helped to establish the cephalomedullary nailing as a viable option in fracture treatment. The fourth article reviews the clinical outcome of this class of nails in comparison to plates. Finally, the last article of this JOT supplement documents the ongoing evolution of intramedullary nailing by a new surgical approach to proximal tibial fractures. The rich and intriguing history of the IMN continues and foreshadows a future of further innovation and improved patient care.
Copyright remains with the authors and publisher.
Many attempts to use the medullary cavity of long bones for fracture fixation had been made over the past 500 years starting with Aztecs (16th century), Dieffenbach (1846), Bircher (1887), Gluck (1890), Senn (1893), Nicolaysen (1897), Lambotte (1907), Hey Groves (1910), Schöne (1913), Hoglund (1917), Rush (1936), and many others. However, none of these pioneers succeeded in an improved treatment of “one of the most difficult problems of osteosynthesis … —the diaphyseal fracture of the femur” to quote Soeur (1946). It was Gerhard Küntscher who paved the way for an improved outcome in the treatment of these fractures 75 years ago, innovating both the implant and the surgical technique. His work was the true progenitor of the intramedullary nail (IMN) as we know it today. But make your own judgment based on the first article in this JOT supplement. Despite widespread initial concerns, the technique quickly gained attention during World War II and spread throughout Europe due to its “relative ease of management of these severe fractures–both on the part of the patient as well as on that of the attending surgeon,” “sometimes known as medullary nail euphoria” (Schneider 1968). In 1942, 20 European surgeons from Germany, Austria, France, and Italy had already adopted the method; the number increased to 60 investigators in 1944, including Häbler, Maatz, Böhler, and Soeur, all of whom published on the topic in the 1940s. The United States learned about this technique in March of 1945, when Time magazine published an article entitled “Amazing Thighbone,” describing an American soldier treated with a Küntscher nail by German doctors for a fracture of his femur. US surgeons called the nail technique “a daring operation” and wondered how their German colleagues inserted it without dangerously injuring the medullary blood supply and without introducing infection. Finally, the reaction in the United States almost duplicated what happened earlier in Europe: After initial skepticism, the new treatment was quickly adopted and attempts were made by Hansen/Street (1945), Lottes (1946), MacAusland (1947), Livingston (1950), and Stryker (1950) to enhance the control of rotational forces and to expand indications of the IMN. Unfortunately, the rapid dissemination of the method in combination with a lack of training and education of surgeons, as well as a lack of quality implant stainless steel negatively impacted clinical outcomes, which were addressed in critical reviews from surgical authorities such as Watson-Jones and Böhler. Fortunately, with attention paid to basic principles and the availability of new enabling technologies, the method not only survived in the hands of well-trained surgeons, but also numerous improvements were made in the next decades. In the 1960s, image intensifiers became clinically available. This advancement significantly reduced radiation exposure and the risk of severe burns of surgeon and patient. The first ones to adopt were Küntscher and his “Detensing” nail, as well as Huckstep and his “Kampala” nail in 1968. It seems that also Huckstep first used an IMN made of titanium alloy. As a result, the era of modern locking nails began, offering additional strength and torsional control of the fracture and extending the indications to more complex comminuted fractures. The renewed interest in the procedure resulted in a variety of locking nails on the market, that is, Klemm/Schellmann (1972), Grosse/Kempf (1976), AO (1987), and Russell/Taylor (1992). Closed, reamed, antegrade intramedullary nailing was established as a standard care for femoral shaft fractures (Sanders 1993). So, the second article in this supplement reviews what had been achieved by 1990. Based on the great success of intramedullary nailing in shaft fractures, the 2 main drivers for innovation during the 1990s and 2000s were (1) to extend the indications to extreme proximal and distal femur and tibia fractures and (2) to go beyond pure fracture fixation to improve clinical outcome in terms of, for example, fracture alignment, pain, and range of motion. The retrograde approach as highlighted in the third article covered both of the above objectives, and an entirely new IMN family established in the subsequent years. In his 1940 article, Gerhard Küntscher also reports the use of a “double nail” to treat combined per- and subtrochanteric fractures. After Zickel in New York presented his IMN (1967) for the same indication, the Gamma Nail in 1989 helped to establish the cephalomedullary nailing as a viable option in fracture treatment. The fourth article reviews the clinical outcome of this class of nails in comparison to plates. Finally, the last article of this JOT supplement documents the ongoing evolution of intramedullary nailing by a new surgical approach to proximal tibial fractures. The rich and intriguing history of the IMN continues and foreshadows a future of further innovation and improved patient care.
Copyright remains with the authors and publisher.