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Do you know the history of intramedullary nailing?

Views: 1     Author: Site Editor     Publish Time: 2023-01-15      Origin: Site

The advent of the intramedullary nail revolutionized the treatment of long bone fractures. Although the technique had existed for centuries, it did not achieve its current status until the second half of the 20th century.


The road to success was not always easy, as the technique was met with skepticism and refutation by many scholars in the first half of the 20th century. Today, through innovations in metallurgy, surgical techniques and fluoroscopic skills, intramedullary nailing has become the standard of care for long bone fractures.


Advances in human biomechanical knowledge have made the creation of this modern design possible. Modern intramedullary nailing is characterized by low infection rates, minimal scarring, good fracture stability, and immediate patient mobility.


The historical review conducted in this article aims to summarize the evolution of the intramedullary nail, highlight its important milestones, present the period atmosphere of the first use and subsequent evolution of the intramedullary nail, and introduce the place of the intramedullary nail in modern orthopedics and traumatology (e.g., Figure 1).

 intramedullary nail

The birth of the intramedullary nail

The ancient Egyptians first used an intramedullary device similar to a nail. Complex surgical fracture care was unlikely to have existed so many years ago.


What is certain, however, is that the ancient Egyptians had great embalming techniques stemming from their belief in the resurrection of the body in the afterlife.


This was the case with the mummy called Usermontu found in Tutankhamun's tomb, where a threaded nail was inserted between the femur and tibia to stabilize the knee joint (as in Figure 2).


Archaeologists speculate that the mummy inside the sarcophagus was not Usermontu himself, but someone else who was replaced by ancient tomb robbers in 600 BCE.


2000 years later, Bernardino de Sahagun, an anthropologist on the Hernando Cortes expedition, reported the first use of intramedullary nailing in a living patient in Mexico.


In 1524, he witnessed an Aztec bone surgeon (named "Tezalo") perform an osteotomy using an obsidian knife and then insert a resin rod into the medullary cavity to stabilize the fracture. Due to the lack of adequate surgical techniques and antiseptics, these procedures had a high complication rate and a high mortality rate.

The ancient Egyptians first used an intramedullary device similar to a nail. Complex surgical fracture care was unlikely to have existed so many years ago. What is certain, however, is that the ancient Egyptians had great embalming techniques stemming from their belief in the resurrection of the body in the afterlife. This was the case with the mummy called Usermontu found in Tutankhamun's tomb, where a threaded nail was inserted between the femur and tibia to stabilize the knee joint (as in Figure 2). Archaeologists speculate that the mummy inside the sarcophagus was not Usermontu himself, but someone else who was replaced by ancient tomb robbers in 600 BCE. 2000 years later, Bernardino de Sahagun, an anthropologist on the Hernando Cortes expedition, reported the first use of intramedullary nailing in a living patient in Mexico. In 1524, he witnessed an Aztec bone surgeon (named "Tezalo") perform an osteotomy using an obsidian knife and then insert a resin rod into the medullary cavity to stabilize the fracture. Due to the lack of adequate surgical techniques and antiseptics, these procedures had a high complication rate and a high mortality rate.

1800s: First Steps

Around the mid-1800s, the first medical journals reported on intramedullary nailing. Diefenbach, Langenbeck, Bardenheuer and other German-speaking surgeons were reported to have used ivory nails in the marrow of long bones to treat bone discontinuities.


Meanwhile, Nicholas Senn of Chicago, a researcher and avid military surgeon, conducted experiments with intramedullary fixation. He would use a hollow perforated splint made of bovine bone and insert it into the medulla to treat "pseudarthrosis" after a fracture.


In 1886, Heinrich Bircher of Switzerland described at a surgical meeting the insertion of ivory nails into the medulla for the acute treatment of complex fractures (Figure 3).


A few years later, Themistocles Gluck in Germany created the first ivory intramedullary nail with a hole at the end of the nail, thus introducing the concept of interlocking for the first time.


During the same period, Julius Nicolaysen from Norway was the first to write about the biomechanical principles of intramedullary nailing of proximal femoral fractures. He emphasized the need to increase the length of the intramedullary nail to obtain greater biomechanical advantage and to provide protection for almost the entire bone.


He was also the first to propose the concept of proximal and distal nail/bone interlocking to design static locking. He is considered by some scholars as the father of intramedullary nailing.


By the mid-1800s, pioneers such as Ignaz Philipp Semmelweis in Vienna and JosephLister in Glasgow had laid the foundation for surgical sterilization. This was a groundbreaking achievement because it allowed the development of new surgical techniques under aseptic conditions.

Intramedullary nail

1900s: Evolution

In 1912, British surgeon Ernest Hay Groves was the first surgeon to use a solid metal rod as an intramedullary nail and was a pioneer of the retrograde intramedullary nail approach.


He gained his experience during World War I when he treated patients with infected pseudarthrosis who were reluctant to amputate their limbs. Not only did he describe the first intramedullary nailing technique that allowed osseointegration through minimal trauma, but he was also skilled in using intramedullary nails and smaller nails to fix fractures.


He experimented with implants made of aluminum, magnesium and steel and recognized the importance of biomechanics in fracture healing. Even so, Ernest Hay Groves' technique suffered from a high rate of infection and was therefore not as popular with his contemporaries.


In 1931, Smith-Petersen, an American orthopedic surgeon, introduced a three-winged stainless steel screw for the treatment of intra-articular capsule femoral neck fractures. He designed an open approach that incised the anterior third of the iliac crest, entered the operative field along the anterior edge of the broad fascial tensor, then repositioned the fracture and used an impactor to drive the stainless steel screw into the femoral head (Figure 4).


Because of the success of the Smith-Petersen trial, many surgeons began experimenting with metal implants for fractures. sven Johansson invented the hollow intramedullary nail in 1932; his ingenious innovation used a kerfing needle that allowed controlled radiologically guided insertion of the intramedullary nail. The core technical components he applied are still in use today.


Going one step further, Rush and his brother introduced the concept of the elastic intramedullary nail in 1937.


They used an elastic, pre-bent stainless steel intramedullary nail and attempted to create an intramedullary three-point fixation structure to counteract the tendency for axial displacement around the fracture.


In their concept, the intact soft tissue area acts as a tension band that resists the tension generated by the pre-bent elastic nail. Their construction was limited by the elastic properties of stainless steel, which changed early from elastic deformation to plastic deformation. The latter may lead to secondary displacement and deformity healing.


In addition, intramedullary nails tend to exit at the entrance or penetrate cancellous bone structures, or even perforate within the joint. Nevertheless, the Viennese scholar Ender continued to use this technique as the basis for the Ender school of fracture fixation and it is still used today for flexible fixation of pediatric fractures.

Intramedullary nail

Bone marrow nail

In 1939, German surgeon Gerhard Küntscher, a Nobel Prize nominee, developed a stainless steel intramedullary nail for the treatment of fractures of the femoral stem.


Küntscher and others were inspired by the Smith-Petersen stainless steel screws used to treat femoral neck fractures and believed that the same principles could be applied to stem fractures. The intramedullary nail they developed was initially V-shaped in cross-section and 7-10 mm in diameter.


After cadaveric and animal studies, he presented the intramedullary nail and the surgical approach at a surgical meeting in Berlin in 1940. Initially, his innovation was ridiculed by his German colleagues, although his method gained popularity after World War II.




Hippocrates (460-370 B.C.), the ancient Greek-era physician often referred to as the father of medicine, once said, "He who wishes to perform surgery must go to war"; the same was true of Küntscher.


During the Nazi era, Küntscher was stationed in a hospital on the Finnish front. There, he was able to operate on patients and prisoners of war in the area. He introduced the bone marrow nailing concept using a closed and open surgical approach, respectively.


In the closed approach, he passed the intramedullary nail in a prograde direction through the greater trochanter and placed it on a retraction table operated with a sling. The fracture is repositioned and the nail is inserted in two planes using head fluoroscopy. In the open approach, the intramedullary nail is inserted through the fracture into the medulla through an incision near the fracture line.Küntscher uses the intramedullary nail to treat femoral stem fractures as well as tibial and humeral fractures.




Küntscher's technique gained international recognition only after the repatriation of Allied prisoners of war.


In this way American and British surgeons became familiar with the intramedullary nail developed by Küntscher and recognized its clear advantages in this era of fracture treatment modalities.


Within a short period of time, more and more surgeons around the world began to adopt his method, and Küntscher's intramedullary nail revolutionized the treatment of fractures by reducing the patient's recovery time by almost a year. Patients who would have had to be immobilized in a cast for months could now be mobile in a matter of days.


To date, the German surgeon is considered the key developer of the intramedullary nail, and he has a pivotal place in the history of trauma surgery.

Expanding Intramedullary Nail

In 1942, Fisher et al. first described the use of the marrow-expanding grinding drill to increase the contact area between the intramedullary nail and the bone and to improve the stability of fracture fixation.


Nevertheless, Küntscher introduced the flexible-guided reaming drill that is still used today and supports reaming over the entire length of the medullary cavity of the bone stem to facilitate the insertion of larger diameter intramedullary nails.


Initially, intramedullary reaming was designed to significantly increase the area of bone contact with the intramedullary nail for stable fixation of the fracture and rapid patient movement.


As described by Smith et al, every 1 mm of medullary expansion increases the contact area by 38%. This allows the use of larger and stiffer intramedullary nails, enhancing the overall stability of the fracture fixation structure.


However, although the Küntscher intramedullary nail with its flexible intramedullary reaming drill became a suitable choice of internal fixation device for osteotomy, academia lost favor of it in the late 1960s in favor of the newly developed plates of the Arbeitsgemeinschaft für Osteosynthesefragen (AO).

1960s: The Dark Ages

In the 1960s, intramedullary nailing was suddenly phased out in favor of plate and screw fracture fixation.


Although Küntscher's method operated smoothly, surgeons around the world rejected them because of poor postoperative results.


In addition, some surgeons began to abandon radiation techniques, such as head fluoroscopy, because surgeons became disgusted by the adverse side effects associated with radiation. The development of intramedullary nailing did not stop there, despite the general international consensus for the use of plate internal fixation systems.


Küntscher, a German physician, recognized the advantages of interlocking and developed a cloverleaf-shaped interlocking intramedullary nail, which he named the "detention nail". The Achilles heel of the intramedullary nail design of that era was the inability to stabilize very comminuted fractures or fractures that were displaced into large angles The solution to this problem was the use of locking screws.


The solution to this problem was to stabilize the intramedullary nail with a locking screw.


In this way, the implant could better resist bending and torsional forces while preventing limb shortening. Using a combination of ideas from Küntscher, Klaus Klemm, and Wolf-Dieter Schellmann, the intramedullary nail was developed to provide greater stability by pre-drilling the screw holes proximal and distal to the intramedullary nail, which was locked to the inserted screw.


Over the next few years, advances in fluoroscopic image clarity allowed for the re-selection of fracture closure and reduction techniques.

1970s and 1980s: Revival

In the 1970s, interest in the intramedullary nailing concept of the German surgeon Küntscher was intense.


Closed reduction intramedullary nail fixation for fractures, with its intersection of flexible reaming and interlocking concepts and enhanced clarity of fluoroscopic techniques, drove the advancement and dissemination of this excellent surgical technique, characterized by minimal soft tissue damage, good stability, and immediate patient mobility.


At that time, the academic world was swept up in a series of innovations that drove the development of the second generation of intramedullary nailing.


In 1976, Grosse and Kempf created a partially slotted intramedullary nail to solve the problem of the elastic modulus of the intramedullary nail. The intramedullary nail was not slotted in the proximal region and had a nail hole for the proximal screw, which was inserted at a 45-degree angle to increase the stability strength of the intramedullary nail internal fixation structure.


A few years later, AO joined the trend of intramedullary nail development by developing similarly conceived intramedullary nails (Figure 5)

 intramedullary nailing

In 1984, Weinquist et al. proposed the dynamic approach, which was to enhance fracture end healing by applying larger locking screw holes, removing static locking screws, and subsequently modifying the locking screw holes to oval nail holes in a more modern design.


The purpose of the dynamic approach is to promote fracture healing and to avoid bone nonunion due to late activity.


Currently, intramedullary nailing dynamics has lost its advocates as a stand-alone technique and is currently used only as a more cost-effective solution than complete replacement of the internal fixation system in the treatment of non-healing fractures.


In a biomechanical study, Gimeno et al. reported that the transition zone between the non-slotted and slotted portions of the intramedullary nail resulted in stress concentrations and surgical failure of the internal fixation implant.


To address these problems, Russel and Taylor et al. designed the first non-slotted, non-dilated intramedullary nail in 1986, with satisfactory results.


During this time, the problem of interlocking intramedullary nails also continued to progress, and as we know today, interlocking with the screw through the intramedullary nail pre-drilled hole was the design of Klemm and Schleman in Germany. The insertion of the screw would be guided by freehand fluoroscopy, which would expose the surgeon to a lot of radiation.


Today, this problem has been solved with a distal targeting system that incorporates electromagnetic field tracking technology, fluoroscopically guided freehand technology, and a precise proximal nail installation guide.

1990s: Titanium intramedullary nail

Over the next decade, the Russel-Taylor intramedullary nail became very popular in the international orthopaedic community. The standard of care slowly became intramedullary nailing with static locking of screws, as shown by the results of the study by Brumback et al.


In this prospective study, the results reported that locking produced good results in most cases and was not associated with non-union of the fracture.


Advances in metallurgy led to the emergence of titanium intramedullary nails, which are widely used in the biomedical industry due to their strength, good corrosion resistance and biocompatibility.


The Alta intramedullary nailing system was the first available titanium intramedullary nail, and it has been greatly welcomed by the medical community due to the mechanical properties of titanium, which is a stronger but less rigid metal than stainless steel.


However, the current literature is skeptical as to whether titanium is a more suitable material for internal fixation than stainless steel, especially due to the increased costs associated with the use of titanium.


However, certain advantages of titanium, such as the elastic modulus close to cortical bone and magnetic resonance imaging compatibility, make it an attractive option.


In addition, titanium is a very attractive option when smaller diameter intramedullary nails are required.

Current Trends

After the successes and failures of previous decades, orthopaedic surgeons have much more experience with intramedullary nailing.


Intramedullary nail fixation of femoral, tibial and humeral fractures has become the standard of care for most closed fractures and some open fractures. New targeting and positioning systems have made the procedure simple and reproducible for even the most inexperienced surgeons.


Recent trends show that titanium and stainless steel metals have very high modulus of elasticity and that stresses obscure the irritating stresses needed for bone healing. New biomaterials such as magnesium alloys, shape memory alloys and resorbable materials are currently being tested in academia.


Intramedullary nails made of continuous carbon fiber-reinforced polymers with improved elastic modulus and great fatigue strength are currently available. Magnesium alloys have a modulus of elasticity similar to that of cortical bone and are biodegradable.


Recent studies by Li et al. have shown significant advantages in treating osteoporotic fractures in animal models attributed to the combination of magnesium and zoledronate coating for fracture repair, a modality that may become a treatment for osteoporotic fractures in the future.


Conclusion

Over the years, with significant improvements in intramedullary nail design, metallurgical techniques, and surgical techniques, intramedullary nailing has developed into the current standard of care for most long bone fractures and is an effective, minimally invasive, and reproducible procedure.


However, due to the numerous intramedullary nail designs, a great deal of information is lacking regarding their postoperative outcomes. More research is needed to determine the optimal intramedullary nail type size, characteristics and radius of curvature.


We predict that innovations in the field of biomaterials will spawn the emergence of new intramedullary nail designs.

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