Table Of ContentPractice of Intramedullary Locked Nails
Scientific Basisand Standard Techniques Recommended byAIOD
Springer-Verlag Berlin Heidelberg GmbH
ChiefEditors 1. KEMPF . K.S. LEUNG
Co-Editors A. GROSSE' H.J.T.M. HAARMAN
H. SEIDEL' G. TAGLANG
Practice of
Intramedullary
Locked Nails
Scientific Basis and Standard Techniques
Recommended by
"Association Internationale pour
l'Osteosynthese Dynamique" (AIOD)
With 239 Figures
and 15 Tables
Springer
Chief Editors ISBN 978-3-642-62961-7
Professor Dr. 1. KEMPF
AIOD, 16 Rue du Parc Library of Congress Cataloging-in-Publication Data
67205 StraBburg, France Practice of intramedullary locked nails: scientific basis and
standard technique recommended by AIOD/[I. Kempf, K. S.
Leung, chief editors].
Professor Dr. K. S. LEUNG p.; cm.
The Chinese University of Hong Kong Includes bibliographical references and index.
ISBN 978-3-642-62961-7 ISBN 978-3-642-56330-0 (eBook)
Department of Orthopaedics
DOI 10.1007/978-3-642-56330-0
and Traumatology 1. Internal fixation in fractures. I. Kempf, I. (Ivan),
Shatin, Hong Kong SAR 1928-II. Leung, Kwok-Sui.
[DNLM: 1. Fracture Fixation, Intramedullary - methods.
China
2. Bone Nails. 3. Internal Fixators. WE 185 P895 2002]
RD 103.15 P73 2002
Co-Editors 617.1'5-dc21 2001049375
Dr. A. GROSSE
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Foreword
Medullary nailing is one of the oldest types of in away that did not allow the surgeon to be car
surgical fracture treatment. Splinting afracture by ried away by enthusiasm. They impressed by re
insertion of plugs made of ebony dates back to porting merits and pitfalls alike in a very realistic
the ancient Egyptian culture. As for many other and convincing manner.
types offracture treatment, some outstanding but When we consider the past, we automatically
lone pioneers performed what was in their hands confront the question, "What is next?" Where are
an art based on intuition. But most of them re today's problems and what could the solutions be?
mained lonely pioneers since they could teach The present book discusses the view that medul
neither the basics nor the surgical art without a lary nailing is able to compensate for the distur
deeper understanding of the underlying science. bance to blood circulation brought by the frac
It took the tenacity of Kuntscher to establish ture, the surgical procedures, the instruments and
medullary nailing as an accepted method oftreat the implants. On the one hand, it is apparent that
ment world-wide. It is a method that is attractive there is potential for biological improvements,
because ofits apparent simplicity and tolerance of specifical in terms of avoiding or reducing trau
the procedures. Kuntscher's great achievements mata due to reaming. But this will invariably be
were certainly crowned by his success in convinc achieved at the expense ofstability or strength of
ing other pioneers, such as 1. Bohler and M.E. the fixation. Similar to the possibilities for im
Muller, to accept his procedure and to use it in proving the afferent blood supply, the effects of
addition to their own special approaches. nailing on a patient local circulation and general,
Itisinterestingtonotethatinrespecttowhatwe disseminated, microvascular aggregation must be
todayunderstandtobethestateoftheartinlocked resolved, especially for patients with thoracic
medullary nailing. Kuntscher had visionary ideas trauma. We are convinced that the spirit estab
that led the waybut did not come to fruition. This lished by the group in Strasbourg and Hong Kong
gave the next generation the opportunity to made and maintained by their colleagues and pupils
an essential contribution. Kuntscher's "detention provides good reason to hope that the next step
nail" remained a Cinderella until Klemm and forward is not far beyond the horizon. The pre
Schellmanprovedtheclinicalmerits oflockednail sent book will not only help the clinically active
ing.Thistechnologywidenedthespectrumofindi surgeon and his team, but will serve as a guide to
cations for nailing and improved its safety. As im the researcher and developer in the insatiable
pressive as their achievements were, it took the vi urge to strive for improvements.
sionanddeterminationofIvanKempfstograspthe It is obvious that no single method can solve
idea and to push for its realization. To Arsene all the problems of fracture treatment. Progress
Grosse, an ingenious developer and surgeon, we and success depend on clean concepts and opti
owe atechnology thatwould be acceptedandsoon mal employment of each single method. This is
find world-wide recognition. where the present book, made with care, deep in
Early on, Iwas impressed not only by the tech sight and great experience concerning the impor
nology, its simplicity and its safety, but even more tant technology of medullary nailing by the
so by the school of thought of the Strasbourg authors and editors 1. Kempf and K.S. Leung,
team that devised away ofteaching the system to contributes in an outstanding way.
encourage general acceptance. An important fac
tor that contributed to this acceptance was the Stephan Perren
fact that this school reported clinical experience Davos, 16 December 2000
Preface
Following the steps of Gerhard Kiintscher, the be stabilised using this technique without em
father of intramedullary fixation of fractures, Dr. barking on more complicated and invasive meth
Klemm and Dr. Schellmann from Frankfurt am ods. With many innovative modifications, this
Main, Germany, took up the idea of locking the technique has been applied to managing difficult
nail to the bone in the early 1970s. Professor Ivan trauma conditions as well as a number of other
Kempf and Dr. Arsene Grosse from Strasbourg, orthopaedic conditions. Today, it is our strong be
France, further developed these concepts, putting lief that the use ofintramedullary locked nails in
intramedullary locked nails into clinical practice the management of long bone fractures has be
in a systemic and scientific manner for the first come a well-established philosophy of patient
time. In fact, the introduction of the intramedul management. The principles and applications are
lary locked nail system to musculoskeletal trauma universal and far beyond the limit ofany particu
was considered to be one of the major advance lar instrument or implant. Based on this faith,
ments ofthe 1970s. Throughout these years, hun Practice ofIntramedullary Locked Nails is written
dreds of training courses were organised to pro in the hope that this technique will evolve further
mote the concept and practice ofthe closed treat for the betterment ofpatients.
ment of long bone fractures with this technique. This book describes the use and relevance of
Numerous clinical results have proven the benefi the closed technique of intramedullary locked
cial effect of the technique to patients. Intrame nails in orthopaedic and trauma surgeries. The
dullary locked nail has become an indispensable Practice ofIntramedullary Locked Nails comprises
instrument in fracture management as well as re oftwo volumes: Vol. 1covers the scientific princi
constructive surgery in orthopaedics. Fixing long ples and standard surgical techniques ofintrame
bone fractures with intramedullary locked nails dullary locked nails; Vol. 2 covers the advanced
agrees with the modern concept of minimally in surgical techniques in extended indications. This
vasive surgery. work would not have been possible without the
Intramedullary fixation fulfils the biological re contribution and collaboration of world-leading
quirement for fracture healing and minimises sur trauma centres. The contributions from surgeons
gical trauma. Intramedullary locked nails provide with different areas of expertise throughout the
a favourable biomechanical environment, from world are essential in providing international and
fracture stabilisation to post-operative rehabilita comprehensive views ofthese nailing techniques.
tion. In accordance with the principles of closed
biological treatment of fractures and minimally Ivan Kempf
invasive techniques, most long bone fractures can Kwok-Sui Leung
Acknowledgements
This book could not have been completed after • The council members of the AIOD who have
such an exceptionally long period of preparation supported the project throughout these years of
without the support and contribution of our preparation.
friends and colleagues. Our special gratitude goes • The secretarial staff of the AIOD, especially
to: Mrs. Margot Hamm, Mrs. Michele Obringer
• Our friends and colleagues who prepared the and Ms. Audrey Muller for their patience, en
manuscripts based on the framework proposed durance and perseverance in making the pro
by the editorial board. Without their patience ject progress, for their excellent and profes
and relentless support, this book could never sional secretarial support in preparing the
have become a reality. manuscripts.
• Our co-editors and the members of the editor • Mrs. Christiane Schaeffer-Cinqualbre, who pre
ial board who share our vision in promoting pared the illustrations.
the concept and practice of the closed treat • Mr. Robert Cooley for improving the English
ment of fractures developed by Prof. Gerhard ofthe manuscripts.
Kiintscher with the intramedullarylocked nails. • The staff of Springer-Verlag in Heidelberg,
• Professor Stephan Perren, our dear friend and especially Mrs. G. Schroder, who supported the
colleague, for his kind remarks in the Fore project from the very beginning, and for their
word. expertise in producing and publishing this
book.
Contents
Chapter 1 Chapter 9
Introduction . Femoral Fractures ..... 73
0 • 0 • • • • • • • • • • • •
1. KEMPF and H. SEIDEL K.So LEUNG and Ao GROSSE
Chapter 2 Chapter 10
The Biology of Fracture Healing as Related Tibial Fractures 87
to IntramedullaryLocked Nailing . 5 K.So LEUNG
F. BIGGI
Chapter 11
Chapter 3 Proximal Femoral Fractures: Operative
Bone Circulation and Effects ofExperimental Techniquefor Peritrochanteric Fractures ..... 101
Interventions ... 11 G. TAGLANG
0 •• 0 ••••• 0 ••• 0 •••••••
M. BROOKES
Chapter 12
Chapter4 Humeral Fractures 113
Biologyand PhysiologyofIntramedullary Ho SEIDEL
Reaming in the Fixation of Fractures . 31
0 ••• 0 •
K.S. LEUNG and E.N.M. CHEUNG Chapter 13
Ulnar Fractures 127
0 •• 0 0 •••• 0 ••• 0 0 0 •• 0 0 0 0
Chapter 5 C. LEFEVRE and D. LE NEN
Biomechanics of Locked Intramedullary Fixation
of Fractures 43 Chapter 14
0 ••
D. DAGRENAT and 1. KEMPF Complications of Intramedullary Locked Nailing:
Infection and Infected Nonunion . 135
Chapter 6 K. KLEMMt and D. SELIGSON
IntramedullaryNail Systems 51
Ao SPEITLING Chapter 15
Complications ofCentromedullary Nailing
Chapter 7 (Excluding Infection) 147
0 ••••••••••••
Time of Radiation Exposure During C. LEFEVRE and Do LE NEN
Intramedullary Nailing Procedures 61
J.-c. DOSCH and M.G. DUPUIS Subject Index . 167
0 0 0 0 0 •••• 0 0 0 • 0 0 • 0 0 0 0 0 •
Chapter 8
Distal Targeting in Locking Nails 67
G. TAGLANG
Contributors
Dr. F. BIGGI Dr. K. KLEMM t
Ospedale Maggiore LandgrabenstraBe 5
Azienda USL Citta di Bologna 61118 Bad-Villbeck, Germany
40133 Bologna, Italy
Prof. C. LEFEVRE
Prof. M. BROOKES H6pital de la Cavale Blanche
68 Lakenheath, Southgate Service d'Orthopedie
N14 4RP London, u.K. 29200 Brest, France
Dr. E.N.M. CHEUNG Prof. D. LE NEN
The Chinese UniversityofHong Kong H6pital de la Cavale Blanche
Department ofOrthopaedics and Traumatology Service d'Orthopeclie
Shatin, Hong Kong SAR, China 29200 Brest, France
Dr. D. DAGRENAT Prof. K.S. LEUNG
Cabinet de Chirurgie Orthopedique The Chinese UniversityofHong Kong,
16 Allee de la Robertsau Department ofOrthopaedics and Traumatology
67000 Strasbourg, France Shatin, Hong Kong SAR, China
Prof. J.-C. DOSCH Dr. H. SEIDEL
Centre de Traumatologie et d'Orthopedie Allgemeines Krankenhaus Wandsbeck
10 Avenue A. Baumann Abteilung fur Unfallchirurgie
67400 Strasbourg, France AlphonsstraBe 14
22043 Hamburg, Germany
Dr. M.G. DUPUIS
Centre de Traumatologie et d'Orthopedie Prof. D. SELIGSON
10 Avenue A. Baumann School ofMedicine
67400 Strasbourg, France Department ofOrthopaedic Surgery
UniversityofLouisville
Dr. A. GROSSE 40292 Louisville, KY, USA
Centre de Traumatologie et d'Orthopedie
10 Avenue A. Baumann Dr. Ing. A. SPEITLING
67400 Strasbourg, France Stryker Trauma GmbH
Prof.-Kuntscher-StraBe 1-5
Prof. I. KEMPF 24232 SchOnkirchen, Germany
Association Internationale
pourl'Osteosynthese Dynamique Dr. G. TAGLANG
16 Rue du Pare Centre de Traumatologie et d'Orthopedie
67205 Strasbourg, France 10 Avenue A. Baumann
67400 Strasbourg, France
CHAPTER 1
Introduction
I. KEMPF and H. SEIDEL
Since time immemorial, man has been the victim the pioneers, Hansmann, Sherman, Hey-Groves,
of accidents which led to fractures, and it is Lambotte - inventor of the expression osteosyn
known that cave men, when faced with this prob thesis - and others, it was with Danis [2], who
lem, devised ways of immobilization in order to created the compression plate later taken up and
treat and heal injuries which were a threat to sur perfected by Muller et al. [8] and the Arbeitsge
vival. Splints made ofbranches and fixed in place meinschaft flir OsteosynthesefragenlAssociation
with lianas, applied after an approximate align for the Study of Internal Fixation (AOIASIF), that
ment of the fragments, ensured, in line with the this technique with the compression screw defini
still eternal principles offracture treatment today, tivelyacquired its position ofeminence.
the immobilization ofthe fracture until it healed. The closed procedure developed more slowly.
Gradually methods improved, with splints, ban Using mainly intramedullary implants, pegs made
dages and different devices and especially with of metal, ivory, bovine cortical bone, etc., are in
the development of continuous traction and plas troduced initially through an open site technique.
ter bandages. These methods were used for mil Extra-articular closed nailing of femoral neck
lennia right down to the first halfofthe twentieth fractures devised and implemented by Senn, Del
century with Lorenz Bohler [1] at the height of bet, Royal-Whitman, and Smith Petersen opened
his career and accomplishments. His treatise Die the way to closed intramedullary nailing ofwhich
Technik der Knochenbruchbehandlung (The Tech Kuntscher [5, 6, 7] is rightly considered to be the
nique ofFracture Treatment) [1] represents an un creator. As early as 1940, he set out its principles
equaled survey of this field, taken up and im and the way it could be performed. First he de
proved by Sarmiento with his Functional Bracing vised the hollow nail with a slot and clover-leaf
[9], which freed the joints adjacent to the fracture. section, then reaming, which made it possible to
The indications for this method should still apply use larger nails, and finally, at the end of his life,
and slow down the current trend in developed he laid down the basis for locked nailing.
countries ofoperating on everything. It is still the Kuntscher started a revolution in fracture man
basis of fracture treatment in the developing agement with this new treatment. He was 40 years
countries. old when he published his technique and philoso
Operative treatment of fractures emerged only phy of fracture treatment in the 64th volume of
after the advent ofantisepsis and asepsis. Its ori the Deutsche Gesellschaftfur Chirurgie [5] in 1940
gins lie in the first halfof the nineteenth century in Berlin. His concept was completely new and re
and it developed in two directions: volutionary for the establishment. Kiintscher
• The open procedure with exposure and open reaped a storm of controversy, denial, and perso
reduction ofthe fragments followed by internal nal attacks. His ideas were rejected on the
fixation using the most varied means: bone su grounds of the existing anatomical science and
tures, wiring, stapling, screws, plates and the accepted standards offracture treatment. Even
screws, pegs, pins, nails. today we hear some of these arguments used
• The closed procedure combining reduction against the intramedullary nailing technique.
without opening the fracture site and fixation However, the clinical background is more ad
using implants introduced or placed at a dis vanced than in those pioneering days and there
tance from the fracture. are sufficient experimental data and clinical ex
perience to support the technique. In proposing a
As far as the open technique is concerned, devel direct approach to the medullary canal, Kuntscher
opment focused mainly on techniques using was running against the widely accepted science
screws and plates with screws. After the age of of the bone marrow. In the nineteenth century,
