History of Intramedullary Nails

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					History of Intramedullary Nails

   By Kevin White
   Medical Radiation Technologist
   Waikato Hospital
The Beginnings – 16th Century

                     Bernardino de
                      (Anthropologist), had
                      travel to Mexico and
                      witnessed Aztec
                      physicians placing
                      wooden sticks into
                      the medullary canals
                      of patients with long
                      bone non-union.
Mid 1800’s

                Ivory pegs were
                 inserted into the
                 medullary canal for

                It had been observed
                 that ivory would get
                 reabsorbed in the
                 human bone.

    Gluck recorded the first description of an
     interlocked intramedullary device.

    The device consisted of an ivory
     intramedullary nail that contained 2 holes
     at the end, through which ivory
     interlocking pins could be passed

    Hoglund of United States reported the
     use of autogenous bone as a
     intramedulary implant.

    A span of cortex was cut out and then
     passed up the medullary cavity across
     the fracture site.

         Hey Groves of
          England reported the
          use of metallic rods
          for the treatment of
          gunshot wounds.

         Very high infection

    Smith-Petersen reported the success of
     stainless steel nails for the treatment of
     NOF #s

    The application of metallic intramedullary
     implants began to expand rapidly.

            In the United States,
             Rush and Rush
             described the use of
             metallic Steinman
             pins placed in the
             medullary canal to
             treat fractures of the
             proximal ulna and
             proximal femur.
The Evolution of Kűntscher
Gerhard Kűntscher – 1900-1972

    Gerhard Kűntscher was born in Germany
     in 1900.
Gerhard Kűntscher - continued

    His early interest in
     intramedullary devices resulted
     from his work with the Smith-
     Petersen nail.

    Kűntscher believed the same
     basic science principles would
     be able to be used for
     diaphyseal fractures.
Gerhard Kűntscher - continued

    During development of his “marrow nail” he
     conducted studies on cadavers' and animals.
Gerhard Kűntscher - continued

    The result was a V-shaped stainless
     steel nail that was inserted

    The V-shaped nail was first used in

    By 1947, 105 cases using the V-
     shaped nail had be performed by
     Küntscher and Finnish surgeons.
Gerhard Kűntscher - continued

                       By late 1940s,
                        Küntscher had
                        designed a new nail,
                        the cloverleaf nail.
Gerhard Kűntscher - continued

    While there was some interest in the use
     of Küntscher’s technique in Europe
     during World War II, his method was
     essentially unknown in the US.

    This was until it was described in an
     article published in the March 12, 1945,
     Time Magazine. Titled “Amazing
Medicine: Amazing Thighbone
Monday, Mar. 12, 1945
 At England General Hospital in Atlantic City last week was a wounded soldier with a strangely
     mended femur (thighbone). The man had been treated by the Germans, his captors.

 When the broken bone failed to heal, after weeks of conventional treatment, the soldier was
    operated on. He was mystified to find that his only new wound was a 2½-inch incision above
    the hipbone. Two days later, the German surgeons told him to move his leg; a few days after
    that, they told him to walk. He did. He has walked ever since.

 After his exchange, U.S. Army doctors X-rayed the soldier's leg. They were amazed at what they
     saw: a half-inch metal rod of some kind had been rammed down the thighbone through the
     marrow for three-quarters of the bone's length, thus supplying a permanent, internal splint.

 Mechanically, the surgeons agree, there is no reason such a splint should not work if the lower
    end of the rod were firmly wedged in hard tissue. But in the past, use of internal splints has
    been restricted to slim wire to align broken bones in fingers, toes and arms. In such cases,
    outside splinting is also used and the mended bones are not required to withstand any end-to-
    end pressure. They call the rod technique "a daring operation" and wonder how their German
    colleagues insert it without dangerously cutting down blood supply and without introducing
    infection. Surgeons at the hospital cautiously say they "have no opinion one way or another
    about this case." But they add that they are not quite satisfied with the way the bone is
    mending around the metal crutch, possibly because of impaired circulation.

    Küntscher was not the only person
     experimenting with the use of intramedullary

    Westerborn reported using a V-shaped nail in
     the Scandinavian literature in 1944.

    In 1946, Soeur reported the use of a U-shaped
     nail in a femur, tibia and humerus.
1940’s continued

     In the US, the Hansen-Street nail was
      introduced in 1947. This was a solid diamond-
      shaped nail.

     Inserted using a closed method, to avoid the
      high infection rate.

     Then penicillin allowed the open retrograde
      nailing to avoid side effects of the radiographic
      techniques of the day.

     Two important techniques were
     1.   Intramedullary reamers
     2.   Interlocking Screws

     Both techniques improved stability.
1950’s Intramedullary reamers

                           Flexible reamers
                            were developed by
1950’s      Interlocking Screws

    Modny and Bambara introduced the
     transfixion intramedullary nail in 1953.
        Multiple holes down the length of the nail.
         Allowing placement of screws at 90o angles
         from each other.

            Intramedullary nailing “went
             on hiatus” in the 1960’s. Due
             to increased enthusiasm for
             compression plating of long
             bone fractures.

            Developments still continued
             with the cephalomedullary
1960’s continued

     The development of
      radiological image
      allowed surgeons to
      readopt closed
      nailing techniques.
      With lower risks to
      surgeon and patient.
1970’s and 1980’s

    The exuberance that accompanied the
     advent of compression plating for tibias
     and femurs in the 1960’s quickly
     diminished in the 1970’s.

    Thus renewed interest in refining closed
     nailing techniques appeared.
1970’s and 1980’s continued

                    The dominant design
                     during this period was
                     the slotted cloverleaf-
                     shaped interlocked nail,
                     e.g. the AO and Grosse-
                     Kempf nail.
1990’s and the 21st Century

    Introduction of new titanium nails,
     cephalomedullary devices such as the
     GSH (Green-Seligson-Henry) nail.

    Slotted cloverleaf designs were being
     replaced by non-slotted designs. Which
     provided greater torsional rigidity.

 Two areas of future research.
 1. Biomaterials
          Biodegradable polymers
          Shape memory alloy

 2.   Biological
      1.   Bone morphogenic protein-2 and -7

    Thank you to Kathy Hogan for this opportunity.

    Thank you to Google images for finding all the
     images for the presentation.
Acknowledgements continued

    Thanks to Time Magazine.
        Medicine: Amazing Thighbone
         Monday, Mar. 12, 1945
        www.time.com
Acknowledgements continued

    Bong MR, Kovai KJ, Egol KA. The
     History of Intramedullary Nailing.
     Bulletin of the NYU Hospital for Joint
     Disease, Volume 64, Number 3 & 4,

  This presentation is based very much
     on the above article, thank you to
               the authors!
Good Bye

      Thank you for coming.
       This presentation will be available at

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