Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
The classic 1984 JBJS review of 520 cases of intramedullary (IM) nailing by Winquist, Hansen, and Clawson changed everything for patients with fractures of the femoral shaft.
In North America during the 1960s and 70s, the debate was all about details of traction management for femoral-shaft fractures: Balanced skeletal traction versus Perkins traction, where to place the traction pin, how many weeks until the spica cast and what type of spica cast, and whether a fracture brace was a viable option. At the same time in Europe, the Swiss orthopaedic community, which was the focal point for the AO, was advocating plate fixation to avoid “fracture disease,” pneumonia, and pulmonary emboli by mobilizing patients.
Meanwhile, Kay Clawson had traveled extensively in Europe and became aware of the outstanding results being achieved with closed, reamed, femoral nailing, as published (originally in German) by Gerhard Kuntscher. Dr. Clawson ordered the equipment—including the reamers, intramedullary nails, and fracture table—and had them shipped to the University of Washington in Seattle.
There they sat on a pallet for more than a year until Dr. Clawson sent Bob Smith, one of the chief residents, to Europe to work with Kuntscher directly. Dr. Smith brought back the knowledge to do reamed IM nailing of the femur, and as experience increased, a Spokane farm boy turned orthopaedic resident named Ted Hansen became especially skilled at the procedure. When Dr. Hansen became an attending, he taught the procedure to another highly skilled resident, Bob Winquist.
Experience grew to the point where they were able to publish this classic manuscript with all its tips, tricks, and outcomes, including which fracture patterns could be treated without keeping patients in traction for weeks to maintain length, and which fractures required open cerclage to create length stability. During this time, there were no commercially available interlocking nails, so we developed ways to drill holes through Kuntscher rods and inserted cortical screws through them with free-hand technique. We also began retrograde nailing these fractures by increasing the bend of the rods to allow them to be inserted off the articular surface in the medial condyle.
This paper, which also carefully explains how procedures were refined as the authors’ experience grew from 1968 to 1979, ushered in the standard of care that exists today and spelled the end of traction treatment and plate fixation. It remains one of the most-cited articles in the history of musculoskeletal trauma literature.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
This, and the OrthoBuzz piece about Kuntscher omit the intriguing part of the history–that Kuntscher’s work became known outside of Germany in the early 1940s when British pilots, who were shot down over Germany, and who sustained femur fractures, were repatriated to Britain and the application of his method was seen. (Kuntscher had already started using his technique in 1939.)
Avrum Gratch