During the turn of the century, as Europeans explored the tropics, various exotic materials such as tusks, antlers and the like were sporadically tried for the treatment of non-union [5].
However the first surgeon to begin to think about and experiment with intramedullary fixation was Nicholas Senn of Chicago and Milwaukee. Indeed Senn was German speaking – Swiss German to be exact. Nicholas Senn was born in Buchs, St. Gallen, Switzerland in 1844 and migrated with his family when he was 8 years old to Ashford, Wisconsin (Fig. 1.2). Senn graduated from the Chicago Medical School in 1868, then his residency at Cook County Hospital and then Milwaukee. Senn wrote prolifically, travelled widely, became professor of Surgery at Rush Medical College in 1891, was an avid military surgeon, and experimented on intramedullary fixation using tubular splints made from cow bone. Nicholas Senn completed doctoral studies in Munich in 1877–1878 where his native language, German, must have served him well.
Fig. 1.2
Nicholas Senn
Nicholas Senn’s career is in the mode of surgical chairpersons. His books are filled with important generalities. His pictures in uniform present a view of the age in which he lived. Senn collected books, was president of the American Medical Association, and had a Chicago high school named for him. In his 1893 address to the American Surgical Association Senn showed two methods for stabilizing long bones with cow bone. In one a perforated ‘ferrule’ of cow bone is placed in the medullary canal (Fig. 1.3), in the other the ends of the pseudarthrosis are inserted into a tube of cow bone [6].
The larger diameter of the external bone splint makes it stronger in bending than an internal splint. Actual clinical case examples are lacking. Aware of the problems posed by foreign material in the medullary canal, the treatment of pseudarthrosis at the turn of the century focused on cortical inlay grafts. Strips of bone taken from either the intact bone or from the tibia were either slid or transferred into a slot cut in the bone on either side of a nonunion.
Sir William Arbuthnot Lane, better known for coining the term osteosynthesis and for the use of Lane Plates for fracture fixation, did apply silver coated steel pegs for the treatment of pseudarthrosis. Arbuthnot Lane was an eccentric Scot, who trained and worked at Guy’s Hospital and became an authority on fracture fixation. It appears that Themistocles Gluck, a German doctor’s son born in Romania and Chief of Surgery at the Emperor Frederick Pediatric Hospital in Berlin experimented with intramedullary stabilizers of ivory and also metal in the 1890s [7, 8].
Although inlay graft became the standard treatment for non-union, intramedullary pegging is shown in French surgical texts from 1906. Inserting an intramedullary peg is not particularly easy. The medullary canal of a long bone has an irregular surface which makes it difficult for a conical peg to slide easily. Ernest Hey Groves, a surgeon from Bristol England, developed a method for sliding a peg into the medullary cavity on one side of a non-union and then seating the peg in the canal of the other side using ligatures. An important contributor to the surgery of fractures, Hey Groves was born in India, began in general practice, did a term in physiology at the University of Tübingen, and subsequently developed an interest in experimental fracture healing for which he received the Jacksonian Prize of the Royal College of Surgeons. After World War I, Hey Groves treated a small series of patients with infected pseudarthrosis of the femur using short intramedullary nails driven from the greater trochanter and left to drain protruding proximally [9]. Doubtless this desperate operation was appropriate in patients with infected non-union and an unwillingness to undergo amputation. Hey Groves work is illustrated with inventive procedures particularly for fractures of the proximal femur. These include an ivory peg to replace the femoral head.
There are sporadic examples from this period of intramedullary pegging performed both in Europe and the United States. In 1913, Georg Schöne reported on the bolting [Bolzung] of forearm fractures using silver pins. Working in the surgical clinic at Greifswald, Schöne reported on the nailing of six fractures of the forearm using silver rods inserted at a distance from the fracture. Schöne’s paper indicates he was thinking thoughtfully about the design of nails, about closed technique and about the possibility of bioabsorbable implants [10]. Burghard’s 1914 “A System of Operative Surgery” states that the best method for holding bone surfaces together is by nails, pegs or screws [11]. Lilienthal at the Bellevue Hospital in New York placed an intramedullary aluminum splint in a femur shaft fracture in 1911 [12].
Saalfeld is a small city in the Eastern Part of Germany in Thuringia. Apparently beginning in 1921 a general surgical doctor, Oskar Müller-Meernach began inserting metal bolts into the medullary canal of long bones to stabilize fractures. Müller-Meernach had an interesting career working first at the hospital in Halle, then at the German Hospital in London, England before travelling to work at a German clinic in Hong Kong. He then returned at the beginning of the World War to the Hospital in Saalfeld where he did his work in intramedullary nailing. Müller’s internal splints or “Bolzen” were made either of Krupp’s stainless steel or from chromicized brass. Müller-Meernach published his series in Zentralblatt für Chirurgie in 1933 [13].
Judging from the radiographs which show the considerable difficulty of passing long bolts into the medullary cavity without reaming, his location in a small town with remote university connections, and from the political situation of the day, Müller-Meernach’s collection of cases did not attract attention. Furthermore, the non-operative program for treating long bone fractures of Lorenz Böhler was the accepted pathway of the day for the management of diaphyseal fractures. Küntscher references both Georg Schöne and Oskar Müller-Meernach in his writings about nailing [14].
As early as 1937 L.V. and H.L. Rush [15] began to use long thin flexible steel wires to stabilize long bone fractures. The system of Rush nailing was fully developed to place contoured nails throughout the skeleton. The method continued in Vienna as the Ender school of fracture fixation [16] and survives today in flexible pinning for pediatric fractures. Nailing with stout implants that allow load bearing differs in philosophy from flexible stabilization of fractures with thin wires placed in the marrow cavity, explaining the separate development of these methods. Finally, Robert Danis, Professor at the University of Brussels, began making nails in 1938 and used short intramedullary implants for various fractures including the hip, the fibula, and the calcaneus [17].
1.2 Who Was Gerhard Küntscher, and Why Should He Be Remembered
By the time Küntscher, a consultant at the Kiel Clinic, reported to the spring 1940 Meeting of the German Surgical Society about his first clinical case of medullary nailing of a subtrochanteric fracture of the femur, the ingredients of intramedullary nailing had already, as has been discussed, been performed by others. However, Küntscher instituted three important advances which were the insertion of nails from an entrance point at a distance from the fracture site without necessarily opening for fresh fractures, the use of an implant of sufficient caliber to allow for mechanical function of a fractured limb, and the placement of a medullary implant the full length of the marrow canal.
Gerhard Küntscher was born 6 December 1900 the son of a commercial director in Zwickau. He attended secondary school in Chemnitz. He was seventeen, a Saxon, when the Prussian Kaiser abdicated leaving a confused and chaotic Germany in rebellion. Military units provided some structure and Küntscher like many other young men joined the Eastern Border armed group (Freikorps). In 1919 he served in the Baltic conflict against the Red Army. After studying medicine in Würzburg, Hamburg and Jena he passed the State Exam in medicine in 1925. He worked first as an assistant in Freiburg, then Jena, and in January 1930 became an assistant in Surgery in the University Clinic, Kiel under Prof. Willy Anschütz (Fig. 1.4). As chief, Alfred Wilhelm Anschütz was an admired educator, known as “father of the students.” Anschütz had contact with Sven Johansson in Gothenburg. Johansson had modified Smith-Petersen’s open operation for nailing femur neck fractures by cannulating the S-P nail and then using a guide pin for percutaneous nail insertion.
Fig. 1.4
Gerhard Küntscher in his sixties (Printed with permission from the Medical and Pharmaceutical Collection of the Christian Albrecht University, Kiel, Germany)
Like many prior national guardsmen, Küntscher joined the National Socialist party early and became a section leader. He was after the acceptance of his thesis not only a Privatdozent in Surgery but also a maverick in the hospital. He held parties with the nurses, decorated the doctors’ quarters, improved rations for physicians and generally attracted disapproval from the hospital administration. He used his party connections and status as an ‘old fighter’ to bail himself out of difficulty. Küntscher was also active in denouncing perhaps unpopular colleagues [18]. It was during this time that Küntscher, like Senn and Hey Groves before, began to study the response of bone to various implants in the medullary canal – Küntscher used dogs in his experiments. In 1935 Küntscher’s thesis on the surgical implications of the flow of force in bone using stress coat was accepted, and he was appointed as a Privatdozent and lecturer. It was probably Anschütz who directed Küntscher to review the treatment of femoral neck fractures. In December 1935, Johansson spoke at the meeting of the Northwest German Surgical Society in Kiel. In 1939, Küntscher also reviewed and presented a paper on the use of the metal Smith-Petersen nail for the treatment of femoral neck fractures [19]. Of interest was the apparent paradox that femur neck fractures heal without callus.
Crucial to the practical use of metal nails in bone is the corrosion problem. The steel used in Smith-Petersen nails not only disintegrated long after its placement in the femoral neck, it also had the potential for provoking an inflammatory response in bone. Gerhard Küntscher’s younger brother by 2 years, Wolfgang, was a metallurgist who later became a professor and international expert in the problems of corrosion in iron and steel. One can speculate on the extent of their collaboration in the late 30s. In 1930, Küntscher met the Kiel instrument maker Ernst Pohl. Pohl’s firm specialized in x-ray equipment, traction beds, wheel chairs and surgical implants. In his shop, Pohl made nails of many designs for Küntscher.
Küntscher’s first nail in a fracture in a human was inserted in October or November 1939 and reported at a regular conference of the Kiel Medical Society in December of 1939 before his first case nailing of a subtrochanteric fracture had healed. By the time of the annual meeting of the German Surgical Society (DGCh) in Berlin in March of 1940, Küntscher reported on 13 intramedullary nailings, 11 in the femur. The strategic importance of the immediate mobilization of the injured is a part of his presentation [20]. In 1939, Prof. Anschütz had been replaced by Albert Wilhelm Fischer as chief of the Kiel Surgical Department. Fischer was politically correct with the authorities and work on nailing proceeded vigorously.
Küntscher was placed on active military duty in 1941 and deployed to various locations on the Eastern Front with Russia. At the same time, in 1942, he was made an extraordinary Professor of Surgery. The military value of intramedullary nailing was under discussion and review both by academics and German military surgeons. The most extensive experience was gained at the Vienna Accident Hospital by Lorenz Böhler who concluded that the operation had dangers and should be limited to fractures in the middle third of the long bones [21]. As operation Barbarossa against the Soviets unrolled, Küntscher was deployed to the relatively isolated station hospital at Kemi in Finnish Lapland to be the Chief German medical officer from 1943- September 1944 during the Continuation War. He had equipment from Pohl to do nailing and was to learn about nailing for gunshot fractures [22].
Kiel was under continued aerial surveillance and bombardment throughout the war. By 26 May 1944 the Kiel Surgical Department in the Hospitalstrasse was destroyed. Yet, despite the bombing of the University Hospital and the adjacent Ernst Pohl factory, the Kiel University Surgical Department continued to work at outlying facilities in Haffkrug, Neustadt and Schleswig. The surgeons documented their procedures and were proud of their undiminished productivity [23]. In the series of Military Medical Handbooks, the German Air force commissioned Prof. C. Häbler of Hannover to write a technical manual about nailing clearly acknowledged as “Marknagelung nach Küntscher” [24].
The Germans were interested in Finland because of the strategic importance of the metal nickel. Military Surgeon Küntscher escaped Kemi by air with the Germany army withdrawal to Norway (Operation Birch) in September 1944, and as the War went down, returned to Jutland where he either was a patient or hid out on the diphtheria ward in Schleswig avoiding capture by the British. The first Kiel Clinic book on intramedullary nailing was finally published with Maatz (Fig. 1.5) who put together the text while serving on a hospital ship in the Mediterranean [25]. Küntscher then emerged as Director of the surgical service of the Schleswig-Hesterberg Municipal Hospital in 1946.
Fig. 1.5
Richard Maatz around 1950
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