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`Section I. The Conceptual Basis
`
`1
`
`The Evolution of
`Intramedullary Nailing
`
`Dana M. Street
`
`Intramedullary (IM) nailing is one of the
`greatest advances of this century in the treat(cid:173)
`ment of fractures. Most of its development has
`come about in the past 40 years, and I have been
`privileged to be a first-hand observer and par(cid:173)
`ticipant in this development.
`Prior to the use of metal nails, intramedullary
`fixation was sporadic. The first instance was
`reported by the conquistadores in the 16th cen(cid:173)
`tury. They observed that the Incas and Aztecs
`used resinous wooden pegs in the medullary
`canal of long bones for the treatment of non(cid:173)
`unions. This report is found in a brief paragraph
`in the Spanish archives and gives no details of
`technique, numbers employed, or results. 1
`There are no excavations to date in which bones
`have been found to confirm the conquistadores'
`report.
`Ivory pegs were used by Bircher in 18862 and
`again were reported by Konig of Germany in
`1913. 3 The ivory peg grafts apparently did well
`if strict asepsis could be maintained. They did
`not become encapsulated like a foreign body,
`such as a bullet, but gradually underwent re(cid:173)
`sorption over a period of years. Hoglund re(cid:173)
`ported the use of bone rather than ivory pegs
`in 1917. 4
`About 1907, Lambotte of Belgium employed
`long screws inserted at the tip of the greater
`trochanter and ext~nding into the medullary
`canal of the proximal third of the femur for
`inter- and subtrochanteric fractures. This was
`reported in his book in 1913. 5 Nicolaysen of
`Norway is credited by Watson-Jones as being
`
`the father of intramedullary nailing. 6 He out(cid:173)
`lined the principles of intramedullary nailing
`in an 1897 publication,? emphasizing the need
`to span the medullary canal with nails of max(cid:173)
`imum length. His work, however, appears to be
`confined to the femoral neck rather than the
`shaft.
`Hey Groves of England tried intramedullary
`fixation on gunshot femur fractures during
`World War 1. 8 He used a long cortical graft in
`one case. In three cases, however, he used nails
`closely resembling the nails currently used, but
`they extended only about 3 inches into the dis(cid:173)
`tal fragment. They filled the canal and were
`inserted in a retrograde fashion through the
`fracture site, features of design and technique
`employed later by others. He used three pat(cid:173)
`terns of nails, but they all failed, apparently
`because of infection. The patient with the graft
`died after amputation, and Groves apparently
`abandoned the method without further trials.
`Belgium surgeons Lambotte, in 1924, and
`Joly, in 1935, reported the use of Kirschner
`wires for IM fixation of forearm fractures. In
`1937, L.V. and H.L. Rush contributed the first
`American description of IM fixation. They used
`medullary Steinmann pins for ulnar fractures
`and later (1939) reported pin fixation for fem(cid:173)
`oral fractures as well.9 Rush developed a flex(cid:173)
`ible nail system, including four different-sized
`diameter pins for use in all parts of the body,
`which he described in his 1956 book. 10 Other
`early reports in the use of medullary pins in(cid:173)
`clude those of Lambrinudi (forearm, 1939},11
`
`1
`
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`2
`
`THE EVOLUTION OF INTRAMEDULLARY NAILING
`
`Murray (clavicle, 1940),12 and the American
`surgeon, Dickson (forearm, 1944).13
`Successful intramedullary nailing as we
`know it began during World War II with the
`work of Kuntscher, whose first publication ap(cid:173)
`peared in 1940.14 In the following sections, the
`history and evolution of intramedullary nailing
`is divided into five decades as a convenient
`time framework for placing the various devel(cid:173)
`opments.
`
`THE FIRST DECADE (1940 to 1949)
`
`Kuntscher's initial work with animals used
`three-flanged nails similar to those employed
`for the femoral neck. His first presentation of
`the method as used in humans, however, de-
`
`scribed the V-shaped nail which filled the canal
`and was also compressible, providing a snug fit
`for greater stability.14 By the time of his first
`publication, the Kuntscher method was already
`well advanced and it even included theY nail
`for intertrochanteric fractures.
`While other orthopedists in Germany at first
`resisted the concept and regarded it as unphys(cid:173)
`iologic,15 the advantages were so apparent that
`they soon concurred and papers began to appear
`by his colleagues. Under the impetus of World
`War II, the method quickly spread over Ger(cid:173)
`many and Austria and later into France and
`Italy. By the end of 1942, there were over 38
`references in the European literature by 26 sur(cid:173)
`geons as found in the combined lists of Bohler
`and Kuntscher.
`
`\
`
`I~
`
`B
`
`c
`
`D
`
`Fig. 1-1. A, C-shaped extractor designed by Maatz. B, Slide weight extractor designed by Stor. C, Toothed extractor designed by
`Westerborn. D, Intramedullary forceps designed by Maatz.
`
`ZIMMER 1041
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`THE EVOLUTION OF INTRAMEDULLARY NAILING
`
`3
`
`Fig. 1-2. Early closed reduction performed with the use of multiple slings.
`
`Noteworthy among the early papers was one
`by his chief, Fischer, and associate, Maatz, de(cid:173)
`scribing instrumentation for the method. 16
`These included a windlass type of extractor, the
`C-shaped extractor, which became standard
`(Fig. 1-1A), and also a windlass traction ap(cid:173)
`paratus. Maatz, who had a degree in engineering
`before studying medicine, was a gadgeteer and,
`according to Alvis,l? played a major role in the
`development of the sound mechanical princi(cid:173)
`ples of the method and design of nails and in(cid:173)
`strumentation. Among other contributors was
`Stbr, with an extractor consisting of a rod with
`
`a hook at one end, which inserted into the eye
`of the nail, and a heavy weighted sleeve that
`slid along the rod, impacting against a stop at
`the other end (Fig. 1-1B). 18
`The difficult part of the closed nailing pro(cid:173)
`cedure, that of reducing the fragments to align
`thP. r:anal, was initially performed using circum(cid:173)
`ferential straps above and below the fracture,
`which were pulled transversely in opposite di(cid:173)
`rections by ropes anchored to hooks in the walls
`of the operating room (Fig. 1-2).1 9 The reduc(cid:173)
`tion, however, was more easily accomplished
`with the apparatus of Linsmayer20 in which lat-
`
`Fig. 1-3. Reduction apparatus of Linsmayer.
`
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`

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`4
`
`THE EVOLUTION OF INTRAMEDULLARY NAILING
`
`eral traction was applied by windlasses in a
`frame, allowing freer access to the operating
`table (Fig. 1-3). A similar effect was achieved
`with the reduction apparatus of Wittmoser21
`using gear-controlled rings (Fig. 1-4). Unless
`they are well padded, the rings appear to cause
`contusion of the muscles if applied over an ex(cid:173)
`tended period.
`Kiintscher later used a crutch with a strap
`attached near the large end (Fig. 1-5) that
`would control both fragments and used the
`crutch as a long lever arm. This appears in his
`book in 1962. Currently, we are using two tennis
`rackets with the strings removed that are
`slipped over the extremity when it is placed in
`traction. The metal-framed rackets show better
`than the wooden ones in the image intensifier
`view when positioned above and below the
`fracture site.
`By 1943, most of the apparatus and nail pat(cid:173)
`terns had been designed and included the
`change from the V-shaped nail to the cloverleaf
`for the femur. The cloverleaf nail provides more
`strength and better follows a guide pin.
`The first book on the subject by Kiintscher
`and Maatz was written for publication in 1942;
`
`but because of the war, it was not published
`until late 1944. It was a limited edition of only
`1000 copies, half of which disappeared. 19 In a
`preface to this book by their Kiel clinic chief,
`Fischer, there is a clear statement of the essence
`of the Kiintscher method:
`The essential feature of Kiintscher's method is
`the introduction of a foreign body from a place
`apart from the fracture site. In this it differs es(cid:173)
`sentially from all other methods of operative treat(cid:173)
`ment. Through the use of a specially shaped, very
`stable, properly constructed nail-like splint, which
`forges an elastic union with the inner surface of
`the marrow cavity, the greatest possible stability
`of the fracture should be achieved, so that a further
`support by plaster cast or traction apparatus is not
`required. By this the disadvantage of a prolonged
`immobility of the limb is avoided. 22
`
`By the end of 1944, 60 authors had published
`150 papers on Kiintscher nailing. Bohler re(cid:173)
`viewed over 500 cases, including 236 from his
`own clinic. In 1944, he published volume III of
`his book, The Technique of Fracture Treatment
`in Peace and War, which was devoted entirely
`to the medullary nailing of Kiintscher. He
`thought it was time to restrain enthusiasm for
`this new method and called attention to serious
`
`Fig. 1-4. Reduction apparatus of Wittmoser.
`
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`

`
`THE EVOLUTION OF INTRAMEDULLARY NAILING
`
`5
`
`\ \
`
`Fig. 1-5. Crutch and strap reduction method of KOntscher.
`
`complications. 23 Kiintscher and Maatz had de(cid:173)
`scribed IM nailing for the femur, tibia, humerus,
`and forearm. While he recognized the great ad(cid:173)
`vantages of this method for femoral fractures,
`he restricted its use in his clinic for all other
`bones. 24 The fatalities attributed to fat embo(cid:173)
`lism following immediate open nailing were
`felt to result from the combination of fat em(cid:173)
`bolism, initial shock from injury, and the
`trauma of extensive open surgery. Therefore, he
`held that open nailing should not be performed
`as an emergency and advised nailing after the
`patient's condition was stable. He felt primary
`closed nailing was acceptable, and delayed
`nailing of open fractures until after debride(cid:173)
`ment.
`In summary, at the end of the first 5 years,
`Kiintscher had established a method with
`highly developed instrumentation that had
`undergone trial in hundreds of cases in Europe,
`although there was little knowledge of it in
`North America. The method was based on two
`principles. First, it provided a stable fixation
`that allowed the patient to return immediately
`to normal activities. This was done by using
`longer nails than those of Hey Groves and larger
`nails than the bolts of Miiller-Meernach. These
`nails were compressible to give a snug fit.
`
`Kiintscher compared the holding power of his
`nail to a nail driven into wood where Lhe com(cid:173)
`pressible wood binds the firm nail, and simi(cid:173)
`larly the compressible nail binds in the firm
`bone (Fig. 1-6). This is only true, however,
`when fixing isthmus fractures when the nail
`obtains a snug fit on both sides.
`The second principle was that of closed nail(cid:173)
`ing with the point of insertion far removed from
`the fracture site. Closed nailing limits the dam(cid:173)
`age to parosteal soft tissues and blood supply,
`thereby lowering the risk of infection and non(cid:173)
`union. Prior to the development of the image
`intensifier, radiographic control of reduction
`and nailing required the use of the head fluoro(cid:173)
`scope (Fig. 1-7). This resulted in excessive ra(cid:173)
`diation exposure of the surgeon's thyroid.
`Other similar nails developed during World
`War II included those of Soeur and Westerborn.
`Soeur's nails were grooved, round V2A steel
`bars, essentially Kiintscher U-shaped, with a
`sharp, oblique point on one end and an eye at
`the other. His nails were relatively small, less
`than 9 mm for the femur, but straight, thereby
`wedging into the irregular bowed canal, and
`traversed the entire length of the femur (Fig.
`1-8). He used the Star extractor and a novel
`driver with a sleeve containing a punch that
`
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`

`
`6
`
`THE EVOLUTION OF INTRAMEDULLARY NAILING
`
`B
`
`Fig. 1-6. A, The nail achieves fixation in the wood through the elastic compression of the nail. B, The cloverleaf Kuntscher nail
`achieves fixation in the isthmus through the elastic expansion of the compressed nail.
`
`had graduations showing the nail penetration
`(also the extent of nail protrusion above the
`bone). He began nailing in 1943, and by the time
`of his report in 1946, 25 he had a series of 55
`operations, including 23 femora, 10 tibiae, 9
`humeri, and 16 forearm bones.
`Westerborn, of Gothenburg, Sweden, also
`began nailing in 1943. He reported his first 28
`cases in 194426 but later noted that there had
`been little in American literature concerning
`"marrow nailing." He therefore published his
`expanded series of 100 cases in the Annals of
`Surgery in 1948. 27 He discussed the three chief
`concerns of the earlier authors and of the profes(cid:173)
`sion at large, namely: the risks of marrow de(cid:173)
`struction, fat embolism, and osteomyelitis. Loss
`of marrow had little significance because many
`amputees had lost much more marrow with no
`ill effects. Fat embolism, though a certain risk,
`could be due to either the fracture or nailing.
`Osteomyelitis as an extensive infection was
`
`rare. Westerborn confirmed the experience of
`Kuntscher, Fisher, Bohler, and others that when
`deep infection occurred it remained a local os(cid:173)
`teitis at the fracture site because pus escaped
`along the nail, thereby preventing rising pres(cid:173)
`sure. Also noted was Kuntscher's advice to
`drain the area but leave the stable nail in place.
`He reported a series of nailings including 22
`femora, 32 tibiae, 31 humeri, 13 forearm bones,
`and 2 metacarpals.
`Westerborn continued with the V nail for the
`femur as well as for other bones. While snug
`fixation was considered mandatory, an advan(cid:173)
`tage of the V nail was that in the event one nail
`was not sufficiently tight, a second could be
`driven in the groove of the first, particularly in
`the tibia and humerus. This was the basis for
`continued use of the V nail by others as well.2 8
`Westerborn's stainless steel nails, manufac(cid:173)
`tured in Gothenburg, had a series of six holes
`spaced in the butt end that would allow a nail
`
`Fig. 1-7. Early headworn fluoroscopes.
`
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`

`
`THE EVOLUTION OF INTRAMEDULLARY NAILING
`
`7
`
`I
`
`I
`
`Fig. 1-9. Westerborn V nail.
`
`versity centers. Closed nailing, however, was
`soon abandoned in favor of open nailing for
`several reasons. Chief among these was the ex(cid:173)
`tensive exposure to radiation when using the
`small fluoroscope (see Fig. 1-7) necessary to
`allow manipulation of the extremity. While
`closed rodding minimized the risk of infection,
`we in America felt more secure having peni(cid:173)
`cillin, which was not available to the Germans
`in World War II. A Lhird reason was the unpre(cid:173)
`dictable duration of the closed nailing proce(cid:173)
`dure. While a thin individual who had received
`adequate skeletal traction preoperatively could
`be nailed quickly, the stocky, muscular male
`with insufficient traction presented a lengthy
`exercise. It was these "wrestling matches" that
`added to the initial shock and led to intraoper(cid:173)
`ative deaths in some earlier cases.
`By 1945 in America, there were C-shaped or
`split-tubular nails and a tantalum nail devel(cid:173)
`oped by MacAusland. 30 These were never
`widely accepted due to the inherent weakness
`of the C-nail design and the brittleness of the
`tantalum. In 1945, while working together, Han(cid:173)
`sen and I conceived a diamond-shaped nail to
`control rotation. Together we developed the
`nail and began successful clinical trials. 31
`In 1947, we began a comparative study treat(cid:173)
`ing femoral fractures with skeletal traction, dual
`plating, open nailing, and closed nailing. We
`quickly abandoned traction and plating as in(cid:173)
`ferior. Despite initial good results with closed
`nailing, we abandoned it in favor of open nail(cid:173)
`ing following an x-ray burn of a patient'c; skin. 32
`Open nailing was simplified by retrograde in(cid:173)
`sertion of the nail at the fracture site. At first,
`
`Fig. 1-8. Nails of Soeur.
`
`0
`
`to be shortened yet would still retain a hole for
`extraction (Fig. 1-9). He had a unique extractor,
`shaped like the jaws of a snake with a single
`fang that would engage the hole in the nail and
`would lock by a drop ring (see Fig. 1-1C).
`North American surgeons first became aware
`of Kuntscher nailing in 1945 when prisoners of
`war returned from Europe carrying nails inside
`well-healed femora and tibiae with little or no
`sequelae. Their initial reactions were shock and
`disbelief. It was immediately branded as un(cid:173)
`physiologic, and problems such as anemia were
`predicted.
`The first publication in American literature
`that dealt with the use of nails rather than pins
`in major long bones was by Tordoir and Moeys
`in July 1945. 29 At about this time, nails designed
`by Hansen and Street, MacAusland, and others
`became available in America.
`From 1945 to 1950, closed and open nailings
`in this country were performed chiefly in uni-
`
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`

`
`8
`
`THE EVOLUTION OF INTRAMEDULLARY NAILING
`I
`
`there was concern that retrograde introduction
`of the nail without prior reaming could "ex(cid:173)
`plode" the trochanter. This problem was solved
`by the addition of a sharp pointed stud on the
`top of the Hansen-Street nail.3 3 In addition to
`modifying the surgical technique, several tech(cid:173)
`nical improvements were made in nail design.
`For example, a threaded stud was added to the
`Hansen-Street nail in 1948. This permitted at(cid:173)
`tachment of a driver/extractor, thus overcoming
`the problem of locating and attaching the hook(cid:173)
`slot type of extractor.
`When inserting a guide pin retrograde for the
`cloverleaf nail, it was difficult to make sure that
`it would emerge from the proximal femur cen(cid:173)
`tered over the medullary canal. To avoid this,
`
`a series of tubes nested like cork borers was
`devised that could be placed in the canal of the
`proximal fragment and direct the guide pin
`more centrally. 34 This was not widely accepted.
`
`THE SECOND DECADE (1950 to 1959)
`By 1950, nailing had become a well-estab(cid:173)
`lished procedure in America, but the Kiintscher
`open technique was used primarily in univer(cid:173)
`sity centers, while many orthopedists and gen(cid:173)
`eral surgeons elsewhere used the diamond nail
`with its simpler technique, fewer instruments,
`and smaller inventory of nails.
`One of the important design developments
`from this period was my introduction of pre bent
`
`Fig. 1-10. Stryker broach.
`
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`Page 9
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`

`
`THE EVOLUTION OF INTRAMEDULLARY NAILING
`
`9
`
`femoral nails. Another approach was the more
`flexible triflanged nail of Lottes. 35•36 The fem(cid:173)
`oral nail never gained wide acceptance, but the
`tibial nail proved ideal for the triangular canal
`of the tibia and has been the most frequently
`employed nail in this country. 37
`A third technical development was the ad(cid:173)
`dition of a broach as an alternative for reaming.
`This was suggested in 1950 by Stryker, who
`manufactured it in both a diamond and clover(cid:173)
`leaf pattern (Fig. 1-10). 38 We adopted the
`broach immediately for the diamond nail be(cid:173)
`cause it allowed its use in smaller canals in a
`size of adequate strength (11 mm). It provided
`maximum holding power to resist torque, and
`it also avoided reaming the entire canal circum(cid:173)
`ference. The cloverleaf pattern of broach never
`
`gained acceptance, which in my opinion was a
`mistake, because it would have provided better
`control of torque loads than the reamed canal.
`A comprehensive review of the complica(cid:173)
`tions of nailing in which 12 surgeons partici(cid:173)
`pated was published by Watson-Jones in 1950. 6
`This report focused on closed nailing. In ad(cid:173)
`dition to problems discussed earlier, it brought
`attention to the complications of guide-pin mal(cid:173)
`position, causing injury to the femoral artery or
`radial nerve, incarcerated nails and guide pins,
`distraction leading to delayed union, tight nails
`splitting the shaft, bent and broken nails due to
`small diameter or malleable metal, and nail mi(cid:173)
`gration. In a 700-case multicenter study au(cid:173)
`thored by Smith in 1951, 39 the incidence of bro(cid:173)
`ken nails was twice as frequent in the cloverleaf
`
`A
`
`B
`
`c
`
`Fig. 1-11. Early nails for transfixion screws. A, Livingston bar. 8, Modny nail. C, Modny nails with screws inserted. 0, Close-up
`view of Modny nail.
`
`ZIMMER 1041
`Page 10
`
`

`
`of the ilium just lateral to the posterior superior
`iliac spine. I have used this technique success(cid:173)
`fully with the diamond nail, which has some
`advantage here over the square nail because the
`lesser of the two diameters fits better in the
`narrow space between the tables of the ilium.
`Another device developed by McElvenney
`was a plate with a bulbous margin that could
`be placed in the lumen of the cloverleaf nail
`(Fig. 1-13}.44 The other margin projecting
`through the slot in the nail could then engage
`a slot in the cortex of the proximal and distal
`fragments at the fracture site like a key, thereby
`controlling rotation. A somewhat similar ar(cid:173)
`rangement was used with the diamond nail,
`consisting of a sleeve that wrapped around the
`nail to add diameter for the wide subtrochan(cid:173)
`teric part of the canal. From this a fin projected
`into the cancellous bone of the trochanter and
`controlled rotation.
`By the late 1950s, four femoral nails were in
`common use, each based on a different fracture
`concept,33 The single Rush 1/q,-inch nail for the
`femur relied on the spring effect with three-
`
`10
`
`THE EVOLUTION OF INTRAMEDULLARY NAILING
`
`as in the diamond, i.e., 1.3 vs. 0.6%, while bent
`nails were 3 times more common in the dia(cid:173)
`mond than in the cloverleaf, 6 vs. 1.9%. These
`problems were largely overcome with the use
`of larger-diameter nails and stronger metal.
`Several new nails appeared in the early
`1950s. The Livingston bar, a short !-beam pat(cid:173)
`tern pointed at both ends, had short slots for
`cross-pinning with screws (Fig. 1-11A}.40 It
`was made of Vitallium and designed to remain
`in the bone indefinitely. Another nail that al(cid:173)
`lowed cross-pinning but extended the full
`length of the canal was devised by Modny (Fig.
`1-11B, C, D) the same year and reported in
`1953.41 This nail has an X-shaped cross section
`and holes throughout its length that are spaced
`about 1 em apart. The holes are round and lo(cid:173)
`cated at the center of the "X" so that screws can
`be passed through them in either of 2 planes at
`90° angles to each other. The nail showed dis(cid:173)
`tinct advantages for supracondylar fractures
`and for comminuted fractures in which sup(cid:173)
`plementary screws were needed. It can also be
`useful in holding the distraction in a lengthened
`femur or keeping the contact in a shortened
`femur.
`In about 1951, Schneider designed the
`Schneider nail (Fig. 1-12}, which incorporated
`both double-ended and self-broaching fea(cid:173)
`tures.42 The nail was also fluted with a square
`cross section. This principle was later incor(cid:173)
`porated in the Street square forearm pin in 1956
`and provided better control of torque stresses
`than did the then popular Rush pin.
`In 1952, Schneider presented an exhibit at the
`AAOS meeting illustrating the use of his nail
`for hip fusions. 43 Here the nail is inserted into
`the posterior iliac spine and crosses the ace(cid:173)
`tabulum into the modified head, neck, and shaft
`of the femur. To avoid excess flexion and ab(cid:173)
`duction, the nail must be inserted into the crest
`
`Fig. 1-12. Schneider nail.
`
`Fig. 1-13. McEivenney plate used as an adjunct to the clo(cid:173)
`verleaf nail to control rotation.
`
`ZIMMER 1041
`Page 11
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`THE EVOLUTION OF INTRAMEDULLARY NAILING
`
`11
`
`point pressure. Its degree of flexibility and need
`for supplementary support limited its accept(cid:173)
`ance. The cloverleaf nail depended on a snug
`fit at the isthmus. It was usually necessary to
`limit nail length to the upper pole of the patella
`because a longer straight nail could exit through
`the anterior cortex. The Hansen-Street nail was
`not necessarily snug at the isthmus but, as a
`curved nail, could use maximum length to ob(cid:173)
`tain maximum hold in the cancellous bone at
`both ends.
`At the 1957 AAOS meeting, Kuntscher was
`the guest speaker and awakened new interest
`in the cloverleaf nail. He recommended ream(cid:173)
`ing to permit use of larger nails and to obtain a
`larger area of nail-bone contact. He also stated
`that significant reaming was well tolerated be(cid:173)
`cause the periosteum lays down new bone
`around the nail. His changes in apparatus and
`technique were published in 1962.45
`In 1958, Vesely of Birmingham, Alabama, and
`I independently thought of splitting the dia(cid:173)
`mond nail. I thought of splitting the mid portion
`for use in the humerus in a manner similar to
`introducing a closed safety pin into a tube. He
`thought of splitting the end portion of the nail
`fur lhe distal femoral fractures, and later he
`thought of the double-split nail for the com(cid:173)
`bined subtrochanteric and supracondylar frac(cid:173)
`tures (Fig. 1-14). We went independently to
`Frank Wright to manufacture it. Wright said that
`we both had the same idea and should combine
`our efforts, hence, the Vesely-Street nail. To(cid:173)
`gether we tested nails, hand-split with a hack(cid:173)
`saw, in cadaver femurs and presented AAOS
`
`exhibits in 195946 and 1961, and a subsequent
`paper with 103 cases. The preliminary report
`was refused by the Journal of Bone and Joint
`Surgery, and the nail went unreported until
`1965.47
`
`THE THIRD DECADE (1960 to 1969)
`
`The 1960s brought the beginning of several
`techniques that did not take root until the
`1970s. Foremost of these was the use of image
`intensification, which became generally avail(cid:173)
`able about 1967. This lessened the risk of ra(cid:173)
`diation exposure and permitted a return to
`closed nailing with its lessened physiologic in(cid:173)
`sult, lower risk of infection, and better healing.
`I practiced this using the diamond nail, while
`Clawson, King, and Hansen of Seattle used the
`cloverleaf nail and the Schneider nail. 48
`The latter part of the 1960s, however, was a
`period when compression plating was sweep(cid:173)
`ing the world and nailing was no longer of cen(cid:173)
`tral interest in fracture treatment. For this rea(cid:173)
`son, the contribution by Kaessman 49 of
`compression nailing in 1966 also attracted little
`interest. Kaessman employed a tie rod within
`lhe Kilnlscher nail (Fig. 1-15) Lhal was an(cid:173)
`chored by cross-pinning in the distal fragment.
`This pin exerted pressure against the proximal
`end of the nail by a collar locked with a set
`screw after applying pressure with a removable
`spring-loaded device. An American series using
`this device was not reported until 1977. 50
`Compression nailing was also independently
`employed by both Huckstep and me in 1967.
`
`A
`
`B
`
`c
`
`Fig. 1-14. A, One of the original nails hand split with hacksaw (11 mm). 8, Double split for high and supracondylar femoral
`fractures (13 mm). C, Tibial split nail (11 mm).
`
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`

`
`12
`
`THE EVOLUTION OF INTRAMEDULLARY NAILING
`
`A
`
`c
`
`D
`
`Fig. 1-15. Kaessmann compression nail. A, Locating the hole in the mandrel. 8, Insertion of the transverse screw through the
`mandrel followed by insertion of the C-shaped nail. C, Compression is applied with a special calibrated compression device. The
`screw in the proximal locking cup is then tightened on the mandrel to hold the compression. 0, Compressed fixed fracture with the
`implant in place.
`
`Rather than use a separate rod, I cross-pinned
`the distal end of the Hansen-Street nail and
`compressed by screwing a cap on the thread
`stud, which remained in place (Fig. 1-16). An
`exhibit of this at the Academy in 1971 was re(cid:173)
`ported later in the same year. 51 In Huckstep's
`method, he cross-pinned the nail distally with
`one or more screws, applied compression prox(cid:173)
`imally, and then cross-pinned the nail proximal
`to the fracture. This was reported in 1972. 52
`Another compression nail was presented by
`Derweduven, a Belgian, in 1979. 53
`It was not until the middle 1 970s that
`compression plating began to lose favor for the
`
`femur and nailing again became the treatment
`of choice. Any nailed femur is compressed
`while weight bearing, provided it is not locked
`with cross pins above and below the fracture.
`A compression nail, however, is of some ad(cid:173)
`vantage in the first few weeks after nailing, be(cid:173)
`fore weight bearing is begun. It is also of distinct
`advantage in femoral shortening where laxity
`of the shortened muscles allows distraction,
`and is advantageous in controlling rotation
`prior to soft tissue healing in lower third frac(cid:173)
`tures.
`The third technique that began in the 1 960s
`was condylocephalic nailing of intertrochan-
`
`ZIMMER 1041
`Page 13
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`

`
`THE EVOLUTION OF INTRAMEDULLARY NAILING
`
`13
`
`A
`
`Fig. 1-16. Street compression nail. A, Nail mounted target device for distal transfixion screw insertion. B, Distal target device
`in use. C, Application of the compression cap to the threaded stud at the top of the nail produces compression at the fracture site.
`0, Fixed compressed fracture with implant in place.
`
`teric and subtrochanteric fractures. In 1950,
`Lezius 54 reported a technique for inserting a
`short nail through a window high on the medial
`cortex of the femur. It was not until Kuntscher
`dropped the point of insertion to the medial
`condyle that the easier exposure made the
`method practical. Klintscher reported his use of
`a prebowed, somewhat lighter cloverleaf nail in
`1966 in German, 55 which was followed by a
`report in English in 1970. 56 Kuntscher's tech(cid:173)
`nique was further reported by Collada and oth(cid:173)
`ers in Spain in 1969 and 1973. 57 •58 I began using
`the 11-mm Hansen-Street nail as a condylo(cid:173)
`cephalic nail in 1973, which led to the devel(cid:173)
`opment of the diamond-shaped condyloce(cid:173)
`phalic Harris nail in 1975. 59
`
`Concurrent with Kuntscher's development of
`the condylocephalic nail, J. Ender introduced
`the multiple, prebent flexible pin. He reported
`this technique in 1970.60 •61 •62 It was further de(cid:173)
`veloped and popularized by his son, H.G.
`Ender. 63,64
`In 1967, Zickel reported his nail for subtro(cid:173)
`chanteric fractures. 5 5 The design of this nail in(cid:173)
`cluded an enlarged proximal end containing a
`tunnel through which a three-flanged nail ex(cid:173)
`tended into the femoral neck and head; it was
`prevented from backing out by a set-screw in
`the end of the shaft nail. Kuntscher had at(cid:173)
`tempted introducing a small femoral neck nail
`through a hole in the proximal end of a clover(cid:173)
`leaf nail, but this was abandoned due to diffi-
`
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`Page 14
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`

`
`14
`
`THE EVOLUTION OF INTRAMEDULLARY NAILING
`
`culty with insertion. He subsequently devel(cid:173)
`oped theY nail for proximal femoral fractures. 66
`In this implant design, a cloverleaf shaft nail
`passes through a hole in the head and neck nail.
`The Zickel subtrochanteric nail has been suc(cid:173)
`cessful for fractures in this area, and it has
`gained wide acceptance.
`The Zickel nail for supracondylar fractures
`appeared later. 67 These are used in pairs in the
`manner of dual-Rush pinning, and an enlarged
`diameter of the basal end of the nails allows a
`hole for a screw, which further stabilizes com(cid:173)
`minuted fractures and prevents the nails from
`backing out. This corrects the main drawback
`of the dual-Rush pinning, where distal migra(cid:173)
`tion of the medial pin has been a major problem.
`
`THE FOURTH DECADE (1970 to 1979)
`This period was characterized by the decline
`of compression plating and firm reestablish-
`
`ment of medullary nailing for the femur, with
`the return to closed nailing. There was also the
`full development of condylocephalic nailing,
`even extending to include shaft fractures.
`New nails continued to appear in the fourth
`decade. Halloran designed a nail patterned after
`the I beam (Fig. 1-17). 68 It is resistant to bend(cid:173)
`ing stresses, having a major proportion of its
`mass away from the center. Additionally, the
`"I" configuration does not fill the medullary
`space as a snug-fitting tubular nail would. As
`Rhinelander has shown, 69 this may facilitate
`restoration of endosteal circulation. Rotation
`and length are controlled b