JBJS Classics: The Küntscher Method of IM Fixation

JBJS ClassicsOrthoBuzz regularly brings 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 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.

In 1957 Gerhard Küntscher presented his work on intramedullary (IM) nailing to the American Academy of Orthopaedic Surgeons.  His classic JBJS paper on the subject, published in January 1958, summarized his views on this comparatively new technique and encouraged other surgeons to use it for the treatment of long bone fractures and nonunions.

Küntscher pointed out that callus was very sensitive to mechanical stresses, and therefore any treatment method should aim at complete immobilization of the fracture fragments throughout the healing process. External splints, such as plaster casts, did not achieve that, and “inner splints” fixed to the outside of the bone damaged the periosteum.

In advocating for intramedullary fixation, Küntscher was careful to distinguish nails from pins. He was very complimentary about J. and L. Rush, who developed intramedullary pinning, but he pointed out that, unlike pins, nails allowed both longitudinal elasticity and cross-sectional compressibility if they were designed with a V-profile or clover-leaf cross section. This cross-sectional elasticity allowed the nail to fit the canal and expand during bone resorption.

Not only did Küntscher appreciate the biomechanics of the intramedullary nail, but he also pointed out the physical and psychological advantages of early mobilization, particularly in the elderly. He also emphasized that massage was unnecessary—and potentially harmful—during the recovery phase, claiming that any measures that make patients more conscious of their injuries are psychologically disadvantageous.

Küntscher used intramedullary nailing to treat fractures, nonunions, and osteotomies of the femur, tibia, humerus, and forearm. He accepted that it was “a most daring” approach that would destroy the nutrient artery, but he pointed out that proper nailing almost always prevented pseudarthoses and that antibiotics had checked the threat of infection. He said further that perioperative x-rays entailed short exposures and that the “electronic fluoroscope” had, even back then, practically eliminated the risk of x-ray injury to assistants.

The paper clearly illustrates Küntscher’s widespread knowledge and innovative skills. However, it was the subsequent development of locked nails that resulted in intramedullary nailing becoming the treatment of choice for femoral and tibial fractures. Time will tell if modern orthopaedic surgeons will catch up with Küntscher and use nailing for humeral and forearm diaphyseal fractures.

Charles M Court-Brown, MD, FRCSCEd

JBJS Deputy Editor

One thought on “JBJS Classics: The Küntscher Method of IM Fixation

  1. History is a strange thing when considered retrospectively with 20-20 vision.

    Küntscher after initial cadaveric studies in 1939, began inserting his intramedullary devices in 1940 on injured servicemen (German and POWs) and actually presented and published his findings amongst his German peers during the war years.

    Remarkably there is this monograph written in 1944, published in 1945 then translated in 2014

    Similarly there are surviving moving pictures of Küntscher providing instructions on performing intramedullary nailing of the tibia. https://www.youtube.com/watch?v=tCYrzva9mx4 It appears back then either his resident or nurses may be the ones stitching the wounds (nice to know nothing has changed).

    And it was in 1947 when the US Navy invited him to publish his techniques and findings in another monograph: The Marrow Nailing Method. U.S. Fleet, U.S. Naval Forces, Germany, Technical Section (Medical).

    So it was at least another 10 years before Küntscher and his technique were formally introduced to the Academy in 1957.

    Colin Moseley said in his POSNA 2008 Presidential Guest Lecture titled Evidence-based Medicine: The Dark Side: “Twenty years ago I attended my first meeting of EPOS and I found it terribly interesting because so many of the papers were outside my frame of reference. At the coffee break I was talking with a German friend and expressed my amazement at a treatment that had been presented that seemed to me to be unreasonable. He replied that it was his favorite treatment and he used it routinely. My confirmation bias had rejected valid information on the use of flexible intramedullary rods for femoral fractures 10 years before it made its way to North America.”

    So yet another similar technique taking a long time to make the leap across the Atlantic “lake.”

    In this day and age, would this have taken so long to transfer ideas and technology?

    Not likely, but then with every new idea or device, proper trial, monitoring and post-marketing analysis should be made rather than to allow unfettered spread and uptake without surveillance. More importantly, there is a need to be vigilant when dealing with devices newly registered via the 510(k) process, as those claiming (bio/mechano-)equivalence may not be fulfilling due diligence in designing, analysing and monitoring their products as the first device on the market.

    Thus, as surgeons travel through various parts of the world, their eyes and minds should be open to new techniques, but their ears should be even more sensitive to passing comments by other users as well as publications about the experience of other orthopaedic units.

    As a wise man once said:
    ‘If you want to be a cutting-edge surgeon, stay with the times. But your patient may suffer often. But if you want to be a safe surgeon, be five years behind the times’.

    Prof T.K. Shanmugasundaram, ex-president of Indian Orthopaedic Association.
    (as reported by President Elect SICOT, Professor Shanmuganathan Rajasekaran)

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