In 1987 Dr. Stuart Green from Los Angeles, California and Dr. David Seligson of Louisville, Kentucky began a dialogue about an intramedullary supracondylar nail for the treatment of low energy split condylar fractures of the distal femur in the elderly. They wanted a nail that was easy to insert percutaneously with a nail mounted guide for finding the locking holes for screws. They discussed ideas from Rush [8], Huckstep, Modny and Bambara [9], Zickel et al. [10] and Klemm and Schellmann [11]. The first illustrations from Stuart Green were for a portion of straight nail from the Huckstep nail manufactured by the Downs Company in London. At the time Downs’s equipment was not readily available in the United States and innovative new design prototypes were not forthcoming. Richards’ medical (today Smith and Nephew) worked with Seligson in Louisville to produce a nail and nail guide expressly for supracondylar nailing [12].

The first nailings were done in the summer of 1988 and reported to the Kuentscher society at its annual meeting [13]. Seligson invited Green to submit a preliminary paper for publication in Techniques in Orthopedics. The first versions of the Intramedullary Supracondylar nail were 10 and 12 mm in diameter with lengths of 150 and 200 mm. The holes were spaced at intervals the length of the nail. The nail had an 8° bend at the distal end, and the last two holes were placed closer together in the distal segment. The nail had holes for 6.5 mm locking screws. The nail fit to a guide with a side arm to locate the locking holes.

The original clinical cases in Louisville and Los Angeles were performed in elderly patients will low energy fractures and these went well. Postoperatively the regimen was non-weight bearing with active assisted limited flexion (45 at first) of the knee until the leg and the patient began to get better (usually at 6 weeks.) Straight leg raising exercises were prohibited. The patients were placed in a knee immobilizer and subsequently fitted with a long leg brace or a hinged knee brace. The collaboration of Green, Seligson, and Henry in the development of this implant led to the eponym – the ‘GSH’ nail. The early results were reported at the AAOS Annual Meeting in New Orleans in February, 1990 [14].

Independently, Kuis and de Ridder in the Netherlands adapted a short ‘reversed’ Gamma nail for the nailing of supracondylar fractures from the knee. The nail of Kuis and de Ridder was straight and a bit thicker than the GSH nail. Kuis and de Ridder report their first series of 11 patients from eight Dutch Hospitals in 1992 [15]. In Budapest, Sárváry fabricated a nail for retrograde insertion and interlocking and by 1992 documented a similar series of 11 cases (Fig. 20.3a–f).

The results with these early cases were surprisingly good. They were so go that Dr. David Seligson’s young associate Dr. Steven Henry used the supracondylar nail in young patients as well and in patients with high energy injuries (Fig. 20.4a–f). Innacone and Born began using the nail in Camden, New Jersey and in 1991 reported their cases combined with Henry’s at the Orthopedic Trauma Association Annual meeting in Seattle [16, 17]. Mechanical comparison between the intramedullary supracondylar nail and the much stiffer reversed compression screw showed greater resistance to lateral bending, compression, and torque with the compression screw, but the nail had adequate resistance to varus loading [18].

Green and Seligson devised a simple technique for nailing as a counterpoise to the elaborate method of blade plate fixation. Elderly patients with poor bone would benefit, they reasoned, from an intuitive, short duration operation with minimum local and systemic tissue cost. When the soft tissues are not substantial and bone is paper thin, Kirschner guide wires easily dislodge. Creating an entrance hole with drills and a router is pointless when the blade itself can manually be pushed through the cortex. Therefore the operation was performed on a radiolucent table with the patient is the supine position. A rolled up drape is placed as a bump under the distal femur to put the knee in flexion, restore the antecurvation of the distal femur shaft and relax the gastrocnemii. A good closed reduction is critical. Small incisions for bone holding clamps are sometimes helpful. After the fracture is reduced closed an entrance hole is made through a stab wound located by fluoroscopy. The entrance point is reamed to not more than 13 mm to avoid separating the condyles and the nail pushed not hammered into the distal femur with the bend facing either anteriorly or posteriorly depending on the reduction of the fracture. A locking screw guide assists in finding the holes for 6.5 mm coarse-threaded screws [19].

The details of postoperative care are important to the success of this method. Case series where although the nailing is well done, but the postoperative program is poorly controlled do not do justice to the technique. In the original concept supracondylar retrograde nailing was introduced for the treatment of unstable fractures in elderly patients with osteoporotic bone and limited activity demand. After nailing, the leg is placed in a knee immobilizer. The construct is not stable enough for weight bearing. A therapist, nurse or family member comes by once or twice daily and lifts the leg out of the immobilizer and takes the knee through a short arc of motion (45°). The patient is encouraged to do supine knee setting in the immobilizer. As the leg control returns the patient is advanced to short arc active assisted range of motion of the knee. It takes about 10 days to 2 weeks for swelling to subside sufficiently to fit the leg with a hinged knee brace. At this time the patient can be brought to a standing position in a walker and allowed to bear a little weight on the limb in the brace. It takes about a month before the patient begins to walk again. Usually the elderly patient leads the way by showing the doctors how much more the leg can do as fracture consolidation begins. More is not better and overzealous physiotherapy directed at increased range of motion should not be allowed. Exercises such as abduction and adduction of the leg (‘snow queens’), are pointless, put marked stress on the osteosynthesis, and should be prohibited. Younger patients with better bone and simpler fracture patterns can be progressed sooner. In all cases, sutures are left in place until the wound is convincingly healed. This often takes 3–4 weeks. Most patients are on chemoprophylaxis for thromboembolism for 10 days to 2 weeks following surgery. There is no clear guideline for the duration of therapy. The literature and the litigation over this issue is extensive. The bottom line is that a small number of patients (less than 5 %) embolize no matter the duration or type of prophylaxis. Chemoprophylaxis can create wound problems that usually resolve slowly in time.

When a method is used in new situations it is inevitable that new problems will arise. In supracondylar nailing these difficulties fall into two general categories: complications from the design of the implants and biological complications. Many criticisms were leveled at the supracondylar nail when it was first introduced. Some thought that it would damage the ligaments of the knee. Careful anatomic studies now have shown that the entrance point is anterior to the cruciate ligaments and they are not damaged by the operation. Others opined that there would be a high incident of arthrofibrosis. Indeed many cases show a reduced range of motion from maximal knee flexion, this loss of flexion has not been problematic. One respected and senior trauma surgeon thought that this ‘antigravity’ nail would ‘fall out’; that has not been the case. Finally few cases of septic arthritis of the knee have resulted from the use of the retrograde, transarticular approach to the femur.

As the nail came into more general use particularly in more active and less sedentary patients, complications of the nail design emerged. These included nail breakage particularly through the hole just proximal to the bend in the nail, screw migration, and subsidence of the nail into the knee joint. These problems induced the Richards’ Company to change the form of the implant. The first change in 1992 was to reduce the size of the locking screws to 5 mm with a corresponding decrease of the size of the holes in the nail. This change delayed but did not eliminate the problem of nail breakage. So the screw holes proximal to the bend in the nail were eliminated to produce the so-called ‘five-hole’ nail.

The smaller 5 mm locking screws provide less convincing anchorage particularly in osteoporotic bone of the distal femur. One solution to this problem was the expansion sleeve from Vécsei in Vienna. If ‘Vécsei Bolts’ break, the fragments are hard to remove making the bolts unacceptable for the North American market. Künstcher proposed a cannulated locking bolt for the distal femur. This cannulated bolt was to be introduced through a nail over a guide wire and mated to a threaded nut on the far side. This design was adapted for Seligson by the Richards’ Company with special instruments for insertion through a nail in the distal femur. The bolt is introduced at the far end of the screw and the special washer lies beneath the head of the screw. Since the distal femur is sloped and not flat, these bolts not only are hard to place and countersink but also can be painful and prominent at the knee. The patent for a “Supra Condylus Bone Nail” filed in 1997 by Asche and associates shows a similar locking bolt [20] (Fig. 20.5).