History of Intramedullary Nails

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History of Intramedullary Nails

• By Kevin WhiteMedical Radiation Technologist
• Waikato Hospital

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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.

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Mid 1800s

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

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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.

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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.

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WWI

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

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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.

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1930s

• 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.

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The Evolution of Kuntscher Nailing
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Gerhard Kuntscher 1900-1972

• Gerhard Kuntscher was born in Germany in 1900.

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Gerhard Kuntscher - continued

• His early interest in intramedullary devices
  resulted from his work with the Smith-Petersen
  nail.
• Kuntscher believed the same basic science
  principles would be able to be used for
  diaphyseal fractures.

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Gerhard Kuntscher - continued

• During development of his marrow nail he
  conducted studies on cadavers' and animals.

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Gerhard Kuntscher - 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.

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Gerhard Kuntscher - continued

• By late 1940s, Küntscher had designed a new nail,
  the cloverleaf nail.

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Gerhard Kuntscher - continued

• While there was some interest in the use of
  Küntschers 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

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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.

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1940s

• 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.

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1940s 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.

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1950s

• Two important techniques were developed.
• Intramedullary reamers
• Interlocking Screws
• Both techniques improved stability.

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1950s Intramedullary reamers

• Flexible reamers were developed by Küntscher.

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1950s 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.

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1960s

• Intramedullary nailing went on hiatus in the
  1960s. Due to increased enthusiasm for
  compression plating of long bone fractures.
• Developments still continued with the
  cephalomedullary nails.

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1960s continued

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

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1970s and 1980s

• The exuberance that accompanied the advent of
  compression plating for tibias and femurs in the
  1960s quickly diminished in the 1970s.
• Thus renewed interest in refining closed nailing
  techniques appeared.

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1970s and 1980s continued

• The dominant design during this period was the
  slotted cloverleaf-shaped interlocked nail, e.g.
  the AO and Grosse-Kempf nail.

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1990s 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.

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Future

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

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Acknowledgements

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

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Acknowledgements continued

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

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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!

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Good Bye

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