© Georg Thieme Verlag Stuttgart · New York
11 June 2008 (online)
The intramedullary nailing method which was inaugurated by G. Küntscher in 1940 must be regarded as one of the most revolutionary ideas that has been developed in traumatology. Today, interlocking intramedullary nailing is a standard method with or without reaming for the treatment of closed and, to a certain degree also, open fractures of the femoral as well as the tibial shafts. The development of intramedullary nailing was blocked over almost twenty years until it was again recognized that stabile fixation and early functional treatment provide a significant advantage concerning the cost and efficiency of the hospital treatment, the use of physical therapy and the extreme reduction of the duration of disablement. The implants which are available today guarantee stability in the case of intramedullary nailing even in fractures which are located in the metaphyseal region. Finally, in support of intramedullary nailing it has to be stated that the rate of complications can be reduced, according to the international literature of the past decade, by over 50 % in comparison to other forms of stabilization.
The idea of the pioneer: In 1939 Küntscher performed his first closed intramedullary nailing on a female patient with a subtrochanteric fracture of the femur. In accordance with the principle of elastic locking of the nail to the bone, he first developed a triangular hollow nail which, however, suffered from the disadvantage of rotational instability.
With the development of a nail with a cloverleaf-like profile a better weight-bearing stability was achieved and it now became possible to begin mobilization of the fractured limb directly following the osteosynthesis and thus to reduce or even avoid occurrence of the much feared “fracture disease”.
March 28, 1940 was a memorable day when Küntscher presented his lecture “Intramedullary Nailing of Fractured Bones (Die Marknagelung von Knochenbrüchen)” at the annual meeting of the Germany Society of Surgery (Deutsche Gesellschaft für Chirurgie) in Berlin where he reported his first experiences and results of intramedullary nailing of diaphyseal fractures of the long hollow bones. His procedure was met with vigorous rejection and only his superior at that time, A. W. Fischer, was able to prevent his expulsion from the society. In 1950 he published his standard work “Intramedullary Nailing (Die Marknagelung)” in which he clearly and decisively stated his position: quote “In principle every treatment of a fracture must consist of the placement and maintenance of the bone fragments in the best possible position until the body itself is able to take over this task through newly formed bone”.
According to Küntscher the advantages of intramedullary nailing are well-founded:
The intramedullary nail is placed in an exceptionally hard, barely flexible, compacted tube and thus is appreciably more rigid than a nail in the femoral neck which is completely surrounded by the relatively softer spongy bone. Due to its V-shape the intramedullary nail is pressed in firmly and is shock absorbing. The intramedullary nail is always longer than the femoral neck nail. The intramedullary nail is bent somewhat and can be ideally clamped in the marrow cavity. Due to its V-shape the intramedullary nail has not only a certain lateral but also a longitudinal shock absorbing function. The ideal reposition and retention is only guaranteed by the intramedullary nail.
Today interlocking nailing serves as an easily performable procedure for primary treatment or re-osteosynthesis after failure of a plate osteosynthesis or a refracture of the tibia or femur with the advantage of stabilization and early weight-bearing.
The introduction of intramedullary nailing of the longer hollow bones, especially those of the lower limbs, represents a milestone in the surgical treatment of fractures in these regions. It can the considered as the summary triumph of a visionary idea and although it arose in a period in which circumstances were highly unfavourable for the healthy and ordered acceptance of a medical procedure even though the results were in absolute support of it. Today, intramedullary nailing constitutes the biomechanical principle of a recognised and safe surgical procedure that is widely used clinically and is accepted as an indispensable standard with all its modalities and modularities.
May I also add a final word about the discontinuation of the journal “Osteosynthesis and Trauma Care”? In the few years of its publication it has developed into a scientifically and medically valuable journal. Hearty thanks are due to Professor Vécsei for his untiring efforts, tact and endurance in the service of the journal. In his editorial in issue number 2-3 / 2007 the editor-in-chief of many years' standing explained why publication of the journal has had to come to an end. This is to be regretted but nothing needs to be added to these facts and arguments.
Finally thanks are due to the authors of this last issue who, in response to the encouragement of Georg Thieme Publisher, have made the publication of issue 4 / 2007 possible. They prepared their contributions and manuscripts reliably within a very short time. I hope that they will again be of interest to our readers.
Many thanks to you all.
Prof. Dr. med. K.-K. Dittel
Stuttgart, April 2008