OrthoBuzz 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