Küntscher intramedullary nailing of the tibial shaft fracture. A 19-year evaluation

Marrow nailing developed by Gerhard Küntscher for long tubular bones is an excellent surgical procedure for fractures of the lower leg shaft. It yields outstanding results both with the typical good indications in respect of shape of fracture, localisation and soft tissue conditions and even with atypical borderline and emergency indications where the healing results can be said to be good and satisfactory. Of course long-standing experience is required especially when employing the Küntscher intramedullary nail in the atypical range of indications. This method produces good results even in critical situations if appropriate accompanying measures are taken. Technique, results and complications are described in this article reflecting the experience of 19 years of working with the intramedullary Küntscher nail.     

Disincarceration of a Küntscher nail

Blockage of a Küntscher nail during nailing of a femoral diaphysis was relieved by a vertical osteotomy extending to upper end of nail identified through a trephine hole.     

Comparative strength analysis of selected osteosynthesis materials for pertrochanteric femoral fractures]

Four commercially available hip-fixation devices for stable fixation of pertrochanteric fractures were selected for a biomechanical evaluation, in order to determine, which construction would best support the load of weight-bearing in postoperative period. Intramedullar nailing by Lezius, Küntscher or Ender showed less bending moments than trifin nail-plates or extramedullar plate attachments with plate angles of 130 degrees or 95 degrees, so that bending tension of Lezius-nails were reduced compared to other implants in a proportion of 1.1,6:1,8:2,7. Whenever possible intramedullar nailing should be preferred. For extramedullar fixation of pathologic or unstable pertrochanteric fractures a double-T-plate was constructed, which shows a 3-fold load resistance of a Lezius-nail, 5-fold load-bearing of a 130 degree plate or a trifin nail combination and a 8-fold higher stress tolerance than a 95 degree-plate.     

Treatment of tibial shaft fractures by percutaneous Küntscher nailing. Technical difficulties and a review of 50 consecutive cases

Intramedullary nailing of the tibia is a controversial procedure for fractures of the tibial shaft. Experience with 50 fractures (58% acute, 8% pathologic, and 34% unsuccessfully treated previously by other methods) with an average follow-up period of one year proved that tibial Küntscher nailing is effective. Mean time to clinical union, with patients independently ambulatory and resuming all work activity, was 29 weeks. Union was demonstrated radiographically at 13 weeks. The major complications were delayed union (2 patients), nail protrusion at the knee (2 patients), osteitis (1 patient), and thrombophlebitis (1 patient). Antirotation wires were used in addition to a Küntscher nail for fractures with inherent rotational instability. Blocking screws were used for fractures predisposed to bending. Technical problems arose most often at the nail entrance site, in negotiation of Herzog's curve, and in selection of proper nail length and caliber. With experience and technical skill, even highly complex tibial fractures can be successfully treated by this method.     

Biomechanical studies on fracture fixation mechanism of the clover leaf medullary nail

The intramedullary nailing method described by Küntscher is used widely now as an excellent treatment of the fracture of the long bone. However, it is well known from clinical experience that fracture fixation of the clover leaf nail is not so strong and especially rotational fixation is very poor. For the purpose of re-evaluating fracture fixation mechanism with Küntscher's nail, the following studies were performed. Osteotomized human cadaveric femur was fixed with the clover leaf nail in an ordinary manner. This osteosynthesis model was imbedded in plastic resin (RIGOLAC) in situ. Afterwards this model was cut into specimens 1.5 cm in thickness. The contact area between the bone and the nail was investigated macroscopically and roentgenographically on each specimen. Stress distribution in cross section of some commercially available clover leaf nails was investigated by the technique of photoelastography. Total expansive force of the clover leaf nail was obtained by the calculation based on the measured values. From these investigations the author concludes that the clover leaf nail does not fix the fracture by the expansive spring mechanism only, as was originally claimed by Küntscher.     

Improved quality of life after intramedullary nailing in femoral metastases

Bone metastases are one of the most frequent problems in orthopaedic oncology. Impending fractures require surgical treatment in order to control pain and mechanical disrupture of the bone involved. The femur is the long bone most commonly involved by metastatic carcinoma. Preventive osteosynthesis is considered a good solution in the treatment of femoral metastases, reducing local pain and improving the quality of life. We analyzed clinical and radiographical outcomes of 21 patients with femoral metastases treated with intramedullar nailing at the Orthopaedics Department of Catholic University of Rome from 1997 to 2000. Bone metastases were located in the diaphysis or in the metadiaphysis. The primary tumors were lung in 10 cases, breast in 8 cases and kidney in 3 cases. Proximal or distal localizations constituted the indication for locked nailing. The implants used were: Küntscher nail in 8 cases, Russel-Taylor nail in 8, Recon nail in 2 cases and proximal femoral nailing in 3 cases when osteolysis involved also the femoral neck. Partial weight-bearing with external support was allowed 3 days postoperatively; full-weight bearing was allowed 20 days after operation except in the cases in which a progression of the primary tumor was observed. No infection or pulmonary embolism was observed. Adjuvant chemotherapy or local radiotherapy was used in all cases. Survival rate was related to the type of primary tumor, and varied from 3 months to 2 years. Received: 18 September 2001/Accepted: 3 November 2001     

Stable metal osteosynthesis in ununited fractures and pseudarthroses of the tibia

The plunge nailing osteosynthesis with the Küntscher nail through the tibia tuberosity and with the Bogdanov nail through the medial malleolus provide stable fixation of the fragments. When combined with decortication of the bone diaphysis and autoplasty with translocated bone transplants the method gives consolidation in ununited fractures and false joints of the tibia within 17-21 weeks. The method was used in operations of 20 patients. The follow-up observation of 18 patients lasted longer than a year. All of them resumed their working capacity.     

The impacted intramedullary nail. The detection of an old problem in a new nail

Impaction of an intramedullary nail during extraction is an unpredictable and delicate situation. Its problematic nature is unfolded on a report of two cases, one with a Küntscher nail and one with a modern solid titanium nail. This event is caused by ingrowth of new bone formation into the slot or the dorsal flute respectively. The new bone formation is a mechanical barrier which effectively forces the distal part of the nail to jam against the cortex. Both, the slot of the unlocked reamed clover leaf nail and the wider dorsal flute of the solid titanium nail, realize certain therapeutic concepts. Their factual benefit within the concept of interlocking nailing is doubtful.     

Küntscher intramedullary reaming and nail fixation for nonunion of the forearm.

Twenty cases of nonunion of forearm fractures were treated by the Küntscher method of intramedullary reaming and nailing. Fifteen fractures healed per primam; 2 required renailing; 2 did not heal but the patients benefited from the stabilizing effect of the nail; 1 was lost to follow-up. Even infected cases could be treated successfully by this method, but extensive experience with all the details of the surgical technique may constitute the difference between catastrophic failure and success. Excision of sinus tracts and sequestrectomy were done as a preliminary procedure.     

Development of intramedullary nailing and the interlocking nail

Development of practically feasible methods for intramedullary stabilisation of fragments is inseparably linked to the name of Gerhard Küntscher. The principle of elastic transverse fixation of the nail in the medullary cavity permits its use only in fractures in the median diaphyseal range of tubular bones. For multiple and comminuted fractures Küntscher recommended a so-called "detention" or "locking" nail. This was developed further by Klemm and Schellmann, thus extending the range of indication for intramedullary fragment stabilisation. The origins and phases of development of this method are shown.     

The biomechanical evaluation of intramedullary nails in distal femoral shaft fractures.

The biomechanical parameters (torsional rigidity and compressive strength) for three different intramedullary femoral nails, Küntscher (K), Brooker-Wills (BW), and Küntscher Interlocking (KI) were compared in this study. Fractures were created in the femoral shaft distal to the isthmus with sections removed so that pure torsional rigidity and resistance to compression could be measured. The standard K nail provided no torsional rigidity and only minimal resistance to longitudinal compression. The KI was significantly more rigid under compression than either the BW or the K. In torsional resistance the K nail was significantly weaker than either the BW or KI. The K nail does not provide significant resistance to compression or torsion for use in oblique or comminuted fractures. The BW nail probably provides enough resistance to rotation for use in distal fractures, but probably does not provide enough resistance to compression for use in fractures that are prone to shortening.     

Intramedullary forearm nailing

Nailing of the forearm, beginning with Sch?ne, antedated nailing of the femur and tibia. Its slower development appears due to anatomic problems with the radius, the interdependence of the two bones, and the strong torque loads from the pronators and supinators. Kirschner wires, threaded Steinman pins, Küntscher U nails, and Rush pins were investigated extensively on fracture services before 1954 when a square-shaped nail to improve stability and fracture healing was designed. A broaching point, allowing some bite of the corners into the circumference of a reamed canal, provided better control of torque loads. Closed nailing has many advantages, including early union, low incidence of infection, small scars, less blood loss, and, frequently, relatively short operating time with minimal surgical trauma. Complications and pitfalls during surgery relate mainly to improper nail size and reaming technique. Open fractures led to the highest number of infections, and in highly comminuted fractures nonunion was occasionally seen. In a series of 137 nailed fractures, the nonunion rate was 7%. While the compression plates may give a slightly lower nonunion rate than nailing, the incidence was more than offset by the greater incidence of refractures and disfiguring scars.     

Correction osteotomy and stabilization with the interlocking nail

Compression and angle plates fitted after corrective osteotomies for congenital or post-traumatic bony malalignment entail the disadvantage that a longer period of non-weight-bearing is needed before consolidation. This is in contrast to the advantages of medullary nailing with interlocking nails in dynamic and static applications, which allow early weight-bearing. The interlocking nail can be used after osteotomies to correct derotation and axial malalignment, but also after lengthening and shortening osteotomies, which we perform both as open procedures and as closed procedures with the aid of the Küntscher saw.     

Karbonrahmen Lagerungs- und Repositionshilfe bei der Unterschenkelmarknagelung in unaufgebohrter Technik

Intramedullary stabilisation of long bones is an established treatment option since Küntscher. Especially for tibial nailing different methods were proposed in the past, were as the use of a fracture table was more or less the standard procedure. Since 4 years now we are nailing tibial fractures without fracture table. We are now using more and more a simple carbon fibre-frame, easily assembled by parts of the AO external fixator. So we can minimize the additional iatrogenic soft tissue damage during surgery and the logistic preoperative set-up in the operation theatre is shorter.     

How to remove a Küntscher nail with no eye

Removal of a Küntscher nail is usually a simple procedure. However, this can sometimes be very difficult if there is no eye in the proximal end of the nail, either due to sawing off the end of the rod during its insertion or due to breakdown of the eye when attempting removal.This brief report describes a technique used to remove a nail when previous attempts at removal had resulted in the loss of the eye of the nail and in its burial in the greater trochanter.     

Complications of Küntscher intramedullary nailing in a child: a case report

A fracture of the femur in a 7-year-old boy who was treated with retrograde Küntscher nailing is described. The follow-up period was 8 1/2 years. Deep infection, physeal injury of the femoral head, and trochanteric epiphysiodesis were serious consequences of the surgery.     

The jammed Küntscher nail: a method of releasing the nail and report of a case

A case of jamming of a Küntscher nail is presented and the technique of longitudinal splitting of the femur by which the nail was released is described. The possible causes of jamming are summarized and some precautions are suggested to avoid this dilemma. Other methods of dealing with a jammed nail are reviewed.     

Treatment of fracture of the shaft of the femur in total hip arthroplasty by a combination of a Küntscher nail and a modified cemented Charnley stem.

Eight cases of fracture of the femoral shaft in total hip arthroplasty were treated by a combination of a Küntscher nail and a modified Charnley stem with cement. Radiological union was achieved in all patients at an average of 8 months.     

Infected Non-Union of the Tibial Shaft Treated by Küntscher Intramedullary Reaming and Nail Fixation: A Report of Four Cases

Four cases of infected non-union of the tibial shaft treated by Küntscher intramedullary reaming and nailing are presented, and on the basis of these cases the indications and prerequisites for the method are discussed.     

Open exchange locked nailing in humeral nonunions after intramedullary nailing

Humeral nonunions after cannulated intramedullary nailing have been difficult to reconstruct. In the current study, 23 consecutive patients were treated by open exchange locked nailing with bone grafting. There were 16 men and seven women with a mean age of 46.2 years. The nonunions followed humeral locked nailing in eight patients, Seidel nailing in 13, and Küntscher nailing in two. The average nonunion time was 14.7 months. The nonunions, located at the proximal (1/3) in four humeri, middle (1/3) in 15, and distal (1/3) in four, were antegrade nailed in 10 and retrograde nailed in 13. Nineteen had 8-mm nails and four had 7-mm nails. Supplementary wiring was used in 19 patients. The average followup was 21.4 months. With one surgery, all but one patient (96%) achieved osseous union in, on average, 16.3 weeks. One patient with chronic renal dialysis had persistent nonunion and an osteolytic supracondylar fracture. Other complications included one postoperative radial nerve palsy, one brachial artery injury, and one wire infection. At followup, all patients with solid union had excellent or satisfactory recovery of shoulder function. The average postoperative Neer score (90.7) was significantly better than the average preoperative score (68.5). Two patients had losses of elbow motion of 10 degrees and 20 degrees, respectively. This study shows that humeral nonunion after cannulated intramedullary nailing can be treated effectively by open exchange locked nailing with bone grafting. Supplementary wiring can compress the nonunion and facilitate bone healing.