History of Intramedullary Nails

1. History of Intramedullary Nails By Kevin WhiteMedical Radiation Technologist Waikato Hospital

2. The Beginnings – 16th Century • Bernardino de Sahagun (Anthropologist), had travel to Mexico and witnessed Aztec physicians placing wooden sticks into the medullary canals of patients with long bone non-union.

3. Mid 1800’s • Ivory pegs were inserted into the medullary canal for non-union. • It had been observed that ivory would get reabsorbed in the human bone.

4. 1890 • 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 through.

5. 1917 • 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.

6. WWI • Hey Groves of England reported the use of metallic rods for the treatment of gunshot wounds. • Very high infection rate.

7. 1931 • 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.

8. 1930’s • 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.

9. The Evolution of Kűntscher Nailing

10. Gerhard Kűntscher – 1900-1972 • Gerhard Kűntscher was born in Germany in 1900.

11. 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.

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

13. Gerhard Kűntscher - continued • The result was a V-shaped stainless steel nail that was inserted antegrade. • The V-shaped nail was first used in 1940 • By 1947, 105 cases using the V-shaped nail had be performed by Küntscher and Finnish surgeons.

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

15. 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 Thighbone”

16. Medicine: Amazing ThighboneMonday, 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.

17. 1940’s • Küntscher was not the only person experimenting with the use of intramedullary nails. • 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.

18. 1940’scontinued • 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.

19. 1950’s • Two important techniques were developed. • Intramedullary reamers • Interlocking Screws • Both techniques improved stability.

20. 1950’sIntramedullary reamers • Flexible reamers were developed by Küntscher.

21. 1950’sInterlocking 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.

22. 1960’s • 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 nails.

23. 1960’s continued • The development of radiological image intensification, allowed surgeons to readopt closed nailing techniques. With lower risks to surgeon and patient.

24. 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.

25. 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.

26. 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.

27. Future Two areas of future research. • Biomaterials • Biodegradable polymers • Shape memory alloy • Biological • Bone morphogenic protein-2 and -7

28. Acknowledgements • Thank you to Kathy Hogan for this opportunity. • Thank you to Google images for finding all the images for the presentation.

29. Acknowledgements continued • Thanks to Time Magazine. • Medicine: Amazing ThighboneMonday, Mar. 12, 1945 • www.time.com

30. 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, 2006 This presentation is based very much on the above article, thank you to the authors!

31. Good Bye Thank you for coming. This presentation will be available at www.kevin.neatstuff.co.nz