Intramedullary nailing
The nailing or medullary nailing (the intramedullary bone nailing ) is a surgical method for the treatment of fractures of the long bones where by driving of a long metal pin (medullary or bone-pin) into the, bone marrow is supplied to the break of within the bone. This enables callus formation and biological bone healing . Since a nail only has stability in the longitudinal axis, the rotational stability of modern intramedullary nails is always ensured by locking bolts, which are screwed into the nail from the side through the bone.
history
In 1887 Bircher and König reported on the first intramedullary fixation of broken long bones. In 1916, Ernest William Hey Groves used ivory and beef bones. In 1925, Marius Nygaard Smith-Petersen presented the three-lamellar nail for femoral neck fractures. 39 Kiel cases were published in 1939 by Gerhard Küntscher .
In March 1940 Küntscher presented his intramedullary nail at the 68th meeting of the German Society for Surgery in Berlin. The conference participants were very indignant, as bone marrow was ascribed an irreplaceable role in the vitality of the bone and healing after fractures. At the time, the bone marrow should therefore not be touched. The clinical successes and the advantages of intramedullary nail osteosynthesis gradually convinced even the skeptics at the beginning. The rapid resilience of the injured extremity, the shortened hospital stay and the rapid recovery of the ability to work were the convincing arguments for this osteosynthesis procedure . The long lying times and immobilizations associated with the prevailing therapy at the time often caused considerable complications, such as B. stiffened joints, pneumonia , thrombosis and pulmonary embolism . These complications, some of which were life-threatening, became much rarer thanks to Küntscher's procedure.
Küntscher initially presented an unreamed and unlocked intramedullary nail with a V-shaped cross-section. This means that a steel tube was "wedged" into the medullary cavity for internal splinting. Due to the later clover-shaped cross-section, the nail was clamped elastically from the inside. The next step was the reaming of the medullary cavity in order to achieve a better jamming and thus to obtain an even more stable osteosynthesis. The reaming increased the cross-section and a thicker intramedullary nail could be implanted. In 1942 Richard Maatz began to drill out the medullary canal. For him, it was particularly about creating a form fit in the bone. For this he used conical intramedullary nails. Shortly afterwards, Küntscher also took over the drilling technique. At first he used rigid drills until Ernst Pohl made a flexible, motor-driven medullary drill available in 1955.
In the following years, reamed intramedullary nailing developed into the standard procedure for tibial shaft fractures with little soft tissue damage. In 1972 the Klemm-Schellmann-Nagel and shortly afterwards the Strasbourg or Grosse-Kempf-Nagel (named after Arsène Grosse and Ivan Kempf) were introduced, which additionally offered the possibility of static or dynamic locking. Another development is the intramedullary compression nail, which enables the option to compress the fracture area and thus significantly improve the apposition of the fracture ends. Around 1966, the Kaessmann model with an attached clamping device was the pioneer here.
A few years later, Grosse and Kempf presented a modified nail system at an international symposium in Strasbourg in 1973. This had new aiming devices for the ( proximal ) locking and a distal aiming device that could be mounted and sterilized on the C-arm of the image converter.
present
The current state of the art are intramedullary nails made of largely inert titanium . These implants offer the option of static or dynamic locking as well as compression on the fracture gap. Are supplied closed and easy open fractures of the large tubular bone ( thigh (femur), tibia (tibia), the upper arm bone (humerus)). Other treatments represent outsider applications in special cases. For fractures close to the joints of the above-mentioned bones, there are a number of special implants with special properties such as B. the gamma nail, proximal humeral nail or distal femoral nail. The implants are anatomically preformed on the target bone and are available in various thicknesses and lengths.
In principle, these implants can be left in place, metal removal is not medically necessary. However, the foreign material is often removed after the fracture has healed after one year. On the one hand, this paves the way for any subsequent joint prostheses, on the other hand, locking screws of the intramedullary nails can become too thick and disrupt.
There is no longer any dispute about intramedullary nailing as such. Scientific points of contention are still the reamed versus unreamed nail and the optimal time for the care of seriously injured patients with appropriate osteosynthesis.
Systems
Tried and tested intramedullary nail systems are available for the humerus, femur and tibia. The retrograde femoral nails for distal (supracondylar) femoral fractures are an asset.
disadvantage
When the nail is driven into the fatty bone marrow, fat is always flooded into the bloodstream, which leads to fat embolism in the lungs. With normal lung function , this is usually not a major problem as the fat in the lungs can be broken down quickly. In the case of multiple trauma or other situations in which the lungs are already damaged, such a fat embolism can lead to acute lung failure ( ARDS ) and be fatal. Therefore, there is also a need for research into the optimal time for fracture treatment in such cases. The reamed version of the intramedullary nail also leads to massively increased pressures in the bone and even to an increased rate of fat embolism. In the case of multiple trauma, this is also only used as a second procedure. When inserting the nail, it is usually necessary to drill open the bone in the joint area. Injury to the joint capsule can cause problems in the joint.
advantages
The protection of the periosteum by the nailing method is a great advantage compared to the plate osteosynthesis methods . The protection of the soft tissues in the area of the fracture is also a great advantage of intramedullary nailing compared to all other procedures. In the case of plate fixation, a more or less large cut must be made through the skin and muscles in the area of the fracture.
literature
- Rüdiger Döhler , D. Hasselhof, Friedrich Hennig : Femoral nailing by Küntscher - a 74-year medical history. Der Chirurg 62 (1991), pp. 761-762.
- Carl Häbler : Küntscher intramedullary nailing for broken shafts of long tubular bones , 2nd edition. Urban & Schwarzenberg, Munich 1950.
- Richard Maatz , Wolfgang Lentz , W. Arens, H. Beck: The intramedullary nailing and other intramedullary osteosynthesis. Schattauer, Stuttgart 1983 (with a chapter on the history of intramedullary nailing by Richard Maatz, including intramedullary osteosynthesis by Küntscher using ivory bolts and wires)
Individual evidence
- ^ AT Cross: Gerhard Küntscher - a surgical giant. In: AO Dialogue. 02/2001. (PDF; 359 kB) ( Memento from July 10, 2010 in the Internet Archive )
- ^ Küntscher: The intramedullary nailing of bone fractures. In: Arch. Klin. Chir. 200, 1940, pp. 443-455.
- ↑ R. Maatz: Positive locking in the Küntscher nailing. In: Zbl. f. Chir. 70, 1943, p. 1641.
- ^ Küntscher, Maatz: The technique of intramedullary nailing. Thieme 1945.
- ↑ Contzen: The development of intramedullary nailing and the locking nail. In: Current Traumatology. 17, 1987, pp. 250-252.
- ^ RH Gahr, W. Hein, H. Seidel: Dynamic Osteosynthesis . Ed .: RH Gahr. 1995, ISBN 3-540-58974-0 , pp. 3 .
- ↑ Xin Duan, Mohammed Al-Qwbani, Yan Zeng, Wei Zhang, Zhou Xiang: Intramedullary nailing for tibial shaft fractures in adults . John Wiley & Sons, 1996, ISSN 1465-1858 ( Review on: Cochrane Database of Systematic Reviews [accessed April 30, 2014]).
- ↑ a b Peter V. Giannoudis, Christopher Tzioupis, Hans-Christoph Pape: Fat embolism: the reaming controversy . In: Injury (= Fat embolism and IM nailing ). tape 37 , 4, Supplement, October 2006, pp. S50-S58 , doi : 10.1016 / j.injury.2006.08.040 .
- ↑ a b R. Attal, M. Blauth: Unbored marrow nailing . In: The orthopedist . tape 39 , no. 2 , February 1, 2010, ISSN 0085-4530 , p. 182-191 , doi : 10.1007 / s00132-009-1524-5 .
