Impact of Intramedullary Nailing in the Treatment of Femur Fractures An Evolutionary Perspective.

Today intramedullary nails (IMN) are the gold standard in the treatment of femur fractures. Since its inception, improved design and understanding of the surrounding anatomy has exponentially increased successful patient treatment and outcomes by promoting early mobilization and reliable union. In this review, we provide an in-depth look into the evolutionary process that has led IMN to becoming today's gold standard in femur fractures.

A Brief History of Limb Lengthening.

In the last 35 years, orthopaedic surgeons have witnessed 3 major advances in the technique of limb lengthening: "distraction osteogenesis" facilitated by Gavriil Ilizarov method and infinitely-adaptable circular fixator with fine-wire bone fragment fixation; the introduction of the "6-strut" computer program-assisted circular fixators to effect complex deformity correction simultaneously; and the development of motorized intramedullary lengthening nails. However, the principles and associated complications of these techniques are on the basis of observations by Codivilla, Putti, and Abbott from as much as 110 years ago. This review notes the contribution of these pioneers in limb lengthening, and the contribution of Thor Heyerdahl principles of tolerance and diversity to the dissemination of Ilizarov principles to the Western world.

The Evolution of Remote-Controlled Intramedullary Lengthening and Compression Nails.

The operative elongation of limbs has long been a goal of orthopaedic surgeons. Indeed, the very first external skeletal fixators, although designed for stabilization of displaced fractures, were also used to overcome the posttrauma shortening that so commonly accompanies fracture deformities.

The history of internal fixation of proximal femur fractures Ernst Pohl-the genius behind.

The most frequently used implants for internal fixation of proximal femoral fractures are currently the dynamic hip screw and the intramedullary hip nail. However, little has been written about one of the pioneers in this field, a German genius, the designer Ernst Pohl (1876-1962). Without his involvement the concepts of intramedullary nailing coined by Gerhard Küntscher, Richard Maatz and other surgeons could hardly have been implemented. Through his achievements Pohl has rightly merited his pre-eminent position in the history of bone surgery. This article outlines the extraordinary contribution of Ernst Pohl to the development of skeletal surgery and radiology, as well as other medical disciplines.

[Oskar Müller-Meernach: a practically forgotten pioneer of intramedullary osteosynthesis]. / Oskar Müller-Meernach: Ein beinahe in Vergessenheit geratener Pionier der intramedullären Osteosynthese.

Oskar Müller-Meernach was a surgeon, gynecologist and tropical disease specialist who published numerous papers dealing with a variety of topics; nevertheless, almost no information about his life or legacy is available on the internet. A citation by Gerhard Küntscher, who is generally accepted as being the father of intramedullary nailing, brought attention to this forgotten pioneer. Therefore, the aim of this study was to shed light on his life and achievements as well as to highlight his contribution to intramedullary osteosynthesis (the use of an intramedullary pin made of stainless steel), which has to be considered as the greatest accomplishment of this very versatile physician.

Intramedullary nailing in fracture treatment: history, science and Küntscher's revolutionary influence in Vienna, Austria.

Although the first intermedullary fixation technique was already reported in 1886, successfully inter-medullary nailing did not start until November 1939 when Küntscher's revolutionary technique was applied for the first time. Whereas Küntscher initially stated that his "marrow nail" was suitable for almost every fracture type as well as for other procedures including fixation of osteotomies, joint arthrodesis and pseudarthro-sis treatment he tried to develop an own nail for every possible fracture type through the years. Undoubtedly, Küntscher has to be considered one of the most influential surgeons. Nevertheless, he was never offered a university position and a lot of people did not acknowledge his brilliancy until his death in 1972. Only in Vienna the willingness to seize Küntscher's ideas was high. Therefore, in addition to a historic overview and to fundamental knowledge referring to reamed and unreamed respectively to static and dynamic nailing Küntscher's influence on Viennese researchers is presented in our paper.

History and development of suction-irrigation-reaming.

Excessive intramedullary pressure coincident to surgical procedures requiring entrance and surgical manipulation within the intramedullary canal is a problem that was recognized by Gerhard Küntscher, the godfather of intramedullary nailing. He expressed concern about this phenomenon in his early writings during the 1940's. Although he suggested certain technical methods to moderate the event while doing the surgical procedure he had no solution for absolutely preventing its occurrence. This became more of an issue after he introduced motorized reaming in the mid 1950's to improve the strength of intramedullary fixation. The first to demonstrate that pressure could be avoided during intramedullary surgeries were Lorenzi, Olerud and Dankwardt-Lillieström in the late 1960's. Using a method that employed suction evacuation of intramedullary content prior to reaming, and by introducing irrigation while reaming, they were able to achieve negative pressures during their intramedullary work. They proved that if an IM technique did not inject fat throughout the bone and into the organism there were significant benefits both locally and systemically. With impeccable methodology, they showed fat destroyed the vascularity of the bone and inhibited its revascularization. Systemically, its presence was associated with death and morbidity. K.M. Stürmer, using sheep in studies done in the 1980's, further validated the effectiveness of negative pressure reaming to prevent adverse effects associated with reaming. The attempt to create a device to provide these benefits clinically, however, has been challenging. The group in Muenster did work with a rinsing-suction-reamer (RSR) that showed fat introduction with reaming need not be significantly greater than when using an external fixator. In the US, the effort has focused on developing a reamer that integrated suction and irrigation into its design. This instrument has been given the acronym of RIA (reamer/irrigator/aspirator). The rationale and development of this system is detailed in this paper. Now that the intramedullary canal can be reamed using a negative pressure method this domain, as a unique source of biological material, is being increasingly investigated. The cells and tissue harvested from this space have tremendous therapeutic promise.

The emergence of "implant-pets" and "bone-sheep": animals as new biomedical objects in orthopaedic surgery.

In this paper we examine the role of animals in orthopaedic surgery and research in the 1960s. We describe their different roles as patients and laboratory models in the emergence of two new biomedical objects that we call "implant-pets" and "bone-sheep." For this purpose, the ways of practicing (veterinary) orthopaedic surgery and of "materializing," or bringing into being, complex and heterogeneous biomedical objects are analyzed as the coevolving histories of humans and animals. Focusing on non-discursive material practices, we use the concept of "articulation" in order to explore the inventive and intervening character of biomedical practices that led to the existence of implant-pets and bone-sheep. Our analysis interprets the distribution of human-like and animal-like character features and values to these animals not as the result of a stable animal-human boundary, but as the effect of diverse interactions in contingent historical situations. This dynamic-relational approach makes it possible to investigate the drawing of human-animal boundaries in the making and thus contributes in a new way to the study of animal-human relationships in history.

[Gerhard Küntscher and intramedullary fixation].

Gerhard Küntscher, a German surgeon, was born in Zwickau in 1900. He graduated from the School of Medicine in Jena in 1926. He is renowned for the development of intramedullary fixation as a solution for fixation of fractures in the long bones. He worked in the Freiburg and Hamburg hospitals, but gained most experience during the Second World War, when he was on the Eastern front. In the period 1943-1944, he was the chief surgeon in the German military hospital in Kemio (Finland). After the war, he worked in hospitals is Schleswig and Hamburg until his retirement in 1965. He introduced the method of percutaneous intramedullary nailing in the femur fractures, as well as the interlocking nail, nail fixation of the pertrochanteric fractures and nails for intramedullary osteotomy. He published over 200 papers and 4 books. In his papers, he was often ahead of his time, and today is considered one of the founders of the concept of intramedullary fixation in fractures.

[Two scientific controversies shaping the development of surgery in the 20th century]. / Zwei wissenschaftliche Kontroversen, die die Entwicklung der Chirurgie im 20. Jahrhundert mitbestimmten.

By way of example, two scientific controversies that played a decisive role in shaping and determining the development--in the areas of chest and trauma surgery--of 20th century surgery, were discussed. In the former area, the spectacular method involving the use of a negative-pressure chamber, developed by Sauerbruch in 1904 was described--an innovation representing an enormous step forward in the field of surgery on the chest. However, the method failed to find widespread favour, and the opposite concept involving the use of positive-pressure was developed, and intratracheal ventilation--already under discussion at the beginning of the 20th century--finally won the day, and still remains in use. Medullary nailing of bone fractures as introduced by Küntscher initially prompted controversial discussion and at first appeared to have been rejected--only to find widespread acceptance nevertheless. It continues to be a justified method of achieving a stable osteosynthesis which, thanks to methodological refinements and improvements over the years, is an important option in the list of indications for surgical treatment of bone fractures. All in all, the following remark would appear applicable: An achievement alone does not suffice--someone is needed to recognize and endorse it.