Intramedullary Nails

The Beginnings 16th Century

Bernardino

de

Sahagun
(Anthropologist), had
travelled to Mexico
and witnessed Aztec
physicians placing
wooden sticks into
the medullary canals
of patients with long
bone non-union.

Mid 1800s
Ivory

pegs were
inserted into the
medullary canal for
non-union.

It

had been observed

that ivory would get
reabsorbed in the
human bone.

1890
Gluck

recorded the first description of an

interlocked intramedullary device.

The

device consisted of an ivory

intramedullary nail that contained 2
holes at the end, through which ivory
interlocking pins could be passed
through.

1917
Hoglund

of United States reported the

use of autogenous bone as a
intramedullary implant.

A span

of cortex was cut out and then

passed up the medullary cavity across
the fracture site.

WWI
Hey

Groves of
England reported the
use of metallic rods
for the treatment of
gunshot wounds.

Very

rate.

high infection

1931
Smith-Petersen

reported the success of

stainless steel nails for the treatment of
NOF #s

The

application of metallic intramedullary

implants began to expand rapidly.

1930s
In

the United States,

Rush and Rush
described the use of
metallic Steinman
pins placed in the
medullary canal to
treat fractures of the
proximal ulna and
proximal femur.

The Evolution of Kntscher

Nailing

Gerhard Kntscher 1900-1972

Gerhard

Kntscher was born in

Germany in 1900.

Gerhard Kntscher - continued

His

early interest in
intramedullary devices resulted
from his work with the SmithPetersen nail.

Kntscher

believed the same

basic science principles would
be able to be used for
diaphyseal fractures.

Gerhard Kntscher - continued

During

development of his marrow nail he

conducted studies on cadavers' and animals.

Gerhard Kntscher - continued

The result was a V-shaped stainless

steel nail that was inserted
antegrade.

The V-shaped nail was first used in

1940

By 1947, 105 cases using the Vshaped nail had be performed by

Kntscher and Finnish surgeons.

Gerhard Kntscher - continued

By

late 1940s,
Kntscher had
designed a new nail,
the cloverleaf nail.

Gerhard Kntscher - continued

While

there was some interest in the use

of Kntschers technique in Europe
during World War II, his method was
essentially unknown in the US.

This

was until it was described in an

article published in the March 12, 1945,
Time Magazine. Titled Amazing
Thighbone

1940s
Kntscher

was not the only person

experimenting with the use of intramedullary
nails.

Westerborn

reported using a V-shaped nail in

the Scandinavian literature in 1944.

In

1946, Soeur reported the use of a U-shaped

nail in a femur, tibia and humerus.

1940s continued
In

the US, the Hansen-Street nail was

introduced in 1947. This was a solid diamondshaped nail.

Inserted

using a closed method, to avoid the

high infection rate.

Then

penicillin allowed the open retrograde

nailing to avoid side effects of the radiographic
techniques of the day.

1950s

Two important techniques were

developed.
1.
2.

Intramedullary reamers
Interlocking Screws

Both techniques improved stability.

1950s Intramedullary reamers

Flexible

reamers
were developed by
Kntscher.

1950s

Interlocking Screws

Modny

and Bambara introduced the

transfixion intramedullary nail in 1953.
Multiple

holes down the length of the nail.

Allowing placement of screws at 90o angles
from each other.

1960s
Intramedullary

nailing went
on hiatus in the 1960s. Due
to increased enthusiasm for
compression plating of long
bone fractures.

Developments

still continued
with the cephalomedullary
nails.

1960s continued
The

development of
radiological image
intensification,
allowed surgeons to
readopt closed
nailing techniques.
With lower risks to
surgeon and patient.

1970s and 1980s

The

exuberance that accompanied the

advent of compression plating for tibias
and femurs in the 1960s quickly
diminished in the 1970s.

Thus

renewed interest in refining closed

nailing techniques appeared.

1970s and 1980s continued

The

dominant design
during this period was
the slotted cloverleafshaped interlocked nail,
e.g. the AO and GrosseKempf nail.

1990s and the 21st Century

Introduction

of new titanium nails,

cephalomedullary devices such as the
GSH (Green-Seligson-Henry) nail.

Slotted

cloverleaf designs were being

replaced by non-slotted designs. Which
provided greater torsional rigidity.

Various generation of nails

Consecutive advancements of nails over
years Can be grouped under three
generations 1 st generation primarily act
as splints ,rotational stability is minimal ,
primarly relies on close fit Eg K nail , V
nail

 2nd

generation Improved rotational

stability due to locking screw Eg-Russel
taylor nail. 3rd generation Nails with
various designs to fit anatomocally as
much as possible ,to aid the insertion and
stability Eg -Nails with multiple curves
,multiple fixation systems Tibial nail with
malleolar fixation Various generations of
nails

BIOMECHANICS
When

placed in a fractured long bone,

IM nails act as internal splints with loadsharing characteristics. Various types of
load act on an IM nail: torsion,
compression, tension and bending
Physiologic loading is a combination of
all these forces.

Biomechanics cont,d
The

amount of load borne by the nail

depends on the stability of the
fracture/implant construct. This stability
is determined by Nail Characteristics
Number and orientation of locking
screws Distance of the locking screw
from the fracture site Reaming or non
reaming

Biomechanics contd
Quality

of the bone IM nails are

assumed to bear most of the load
initially, then gradually transfer it to the
bone as the fracture heals

Biomechanics contd
If

cortical contact across the fracture site

is achieved postoperatively, most of the
compressive loads are borne by the
bony cortex; In the absence of cortical
contact, compressive loads are
transferred to the interlocking screws,
which results in four-point bending of the
screws

NAIL CHARACTERISTICS
Several

factors contribute to the overall

biomechanical profile and resulting
structural stiffness of an IM nail. Chief
among them are Material properties
Cross-sectional shape Diameter Curves
Length and working length Extreme
ends of the nail Supplementary fixation
devices Nail Characteristics

Nail characteristics contd

Material

properties Construction of IM
nails are titanium alloy and 316L
stainless steel. Stainless steel has twice
of modulus elasticy of cortical bone
Titanium alloy has a modulus of elasticity
closely approximates that of cortical
bone ( Modulus is ability to resist
deformation in tension )

Nail characteristics contd

The

cross-sectional shape of the nail

,Diameter and the area of the nail
determines its bending and torsional
strengths( Resistance of a structure to
torsion or twisting force is called polar
movement of inertia )

Nail characteristics contd

Circular

nail has polar movement of

inertia proportional to its diameter, in
square nail its proportional to the edge
length Nails with Sharp corners or fluted
edges has more polar movement inertia
Cloverleaf design resist bending most
effectively Presence of slot reduces the
torsional strength. It is more rigid when
slot is placed in tensile side

Nail characteristics contd

Diameter

Nail diameter affects bending

rigidity of nail. For a solid circular nail,
the bending rigidity is proportional to the
third power of nail diameter Torsional
rigidity is proportional to the fourth power
of diameter.

Nail characteristics contd

CURVES

Long bones have curved

medularly cavities Nails are contoured to
accommodate curves of the bone
Average radius of curvature of femur is
120 (36) cm. Femoral nail designs have
considerably less curve, with radius
ranging from 186 to 300 cm

Nail characteristics contd

mismatch

in the radius of curvature

between the nail and the femur can lead
to distal anterior cortical perforation

Nail characteristics contd

Tibial

nail also has a smooth 11 bend in

the anterioposterior direction at junction
of upper one third and lower two third . It
is called angle of herzog

Nail characteristics contd

When

inserting nail, axial force is

necessary as the nail must bend to fit
the curvature of the modularly canal The
insertion force generates hoop stress in
the bone ( Circumferential expansion
stress )

Nail characteristics contd

Greater

the insertion force higher the

hoop stress .Larger hoop stress can split
the bone Over reaming the entry hole by
0.5-1mm ,selecting entry point posterior
to the central axis reduce the hoop
stress

Nail characteristics contd

The

ideal starting point for insertion of an

antegrade femoral nail is in the posterior
portion of the piriformis fossa . It reduces
the hoop stress

Nail characteristics contd

Length

and working length

A-Total nail length- total anatomical
length
B-Working length- Length of a nail
spanning the fracture site from its distal
point of fixation in the proximal fragment
to proximal point of fixation in the distal
fragment.

Nail characteristics contd

working length is affected by various
factors
Type of force (Bending ,Torsion ) Type of
fracture
Interlocking
Reaming

Nail characteristics contd

For

bending loads, a nail fixing a

transverse fracture has a shorter
working length than one fixing a
comminuted fracture.

Nail characteristics contd

For

torsional loads when a nail is fixed to

the bone by interlocking screws working
length equals to the definite points of
fixation

Nail characteristics contd

In

weight bearing, interlocking nail bows

and Increase the nail bone contact near
the fracture site. Increase contact force
reduces the working length for bending
and torsional force

Interlocking screws
Interlocking

screws are recommended

for most cases of IM nailing. The number
of interlocks used is based on fracture
location, amount of fracture comminution
, and the fit of the nail within the canal.
Placing screws in multiple planes may
lead to a reduction of minor movement

Interlocking screws
Interlocking

Screw Static locking- when

screws placed proximal and distal to the
fracture site. This restrict translation and
rotation at the fracture site. Indications
communited , spiral,pathologicalfractures
Fractures with bone loss lengthning or
shortening osteotomies , Atropic non union

Interlocking screws
Dynamic

locking when screws are

inserted only at one end(short proximal
fragment )
Indications - Fractures with good bone
contact, non unions

Interlocking screws
Dynamisation

Removal of locking
screw,it is indicated when there is
nonnunion or pseudoarthrosis screws
are removed from long fragment Can be
perform within 3rd month of treatment, It
enhances fracture healing.

Interlocking screws
stability

depends on the locking screw

diameter for a given nail diameter. In
general, 4 to 5 mm for humeral nails and
5 to 6 mm for tibial and femoral nails. Nail
hole size should not exceed 50% of the
nail diameter. Interlocking screws
undergo four-point bending loads, with
higher screw stresses seen at the most
distal locking sites

Interlocking screws
The

number of locking screws is

determined based on fracture location
and stability. In general, one proximal
one distal screw is sufficient for stable
fractures

Interlocking screws
The

location of the distal locking screws

affects the biomechanics of the fracture .
The closer the fracture to the distal
locking screws, the nail has less cortical
contact , which leads to increased stress
on the locking screws. More distal the
locking screw is from fracture site, the
fracture becomes more rotationally stable
.

Interlocking screws
Oblique

( angled to nail axis, not 90)

proximal locking screws appear to
increase the stability of proximal tibia
fractures compared with transverse ( 90
to nail axis) locking screws. However,
oblique or transverse orientation of the
distal screws in distal-third tibia fractures
has minimal effect on stability.

Interlocking screws
Orientation

of the proximal femur locking

screws has little effect on fixation
stability, with both oblique and
transverse proximal locking screws
showing equal axial load to failure.

Interlocking screws
Two

screws can be inserted at angles to

the cross-section of the nail to decrease
motion between the screws and the nail,
but anatomic structures must be taken
into consideration when performing this
technique.

Closed and open nailing

Closed

nailing Fluoroscopy is used to

achive fracture reduction Medullary
cavity is entered through one end of the
bone antegrade eg-Piriformis fossa in
femur Closed antegrade nailing is the
method of choice Open nailing
Performed in lessthan ideal operation
room conditions

Closed and open nailing contd

Antegrade

nailing is prefered In
retrograde method nail is inserted in to
the proximal fragment through fracture
site and brought out at one end of the
bone ,after reduction nail is driven in to
the distal fragment Infection and non
union is six and ten times greater in
open nailing.

Biomechanics of IM Reaming
IM

reaming can act to increase the

contact area between the nail and
cortical bone by smoothing internal
surfaces. When the nail is the same size
as the reamer, 1 mm of reaming can
increase the contact area by 38%

Biomechanics of IM Reaming
contd
Reaming

reduces the working length

and increase the stability. More reaming
allows insertion of a larger-diameter nail,
which provides more rigidity in bending
and torsion. Biomechanically, reamed
nails provide better fixation stability than
do unreamed nails.

Wt. Bearing after IM nailing

Segmentally

comminuted diaphyseal
fracture without bony contact and nails
with a 12-mm diameter and two distal
locking bolts could with stand the typical
biomechanical forces of weight bearing.
In patients who retain diaphyseal bony
contact after fracture fixation,

Wt bearing after IM nailing

nails

with a diameter <12 mm or nails

with a single distal interlock may provide
adequate stability for weight bearing
because the bony contact reduces the
load encountered by the distal
interlocking screws. weight bearing
through a locked IM nail could be allowed
in fractures in which 50% cortical contact
is present

IM failure
As

with all metallic implants, there is a

relative race between bone healing and
implant failure. Occasionally, an implant
will break when fracture healing is
delayed or when nonunion occurs. IM
nails usually fail in predictable patterns.

IM failure contd
Unlocked

nails typically fail either at the

fracture site or through a screw hole or
slot. Locked nails fail by screw breakage
or fracturing of the nail at locking hole
sites, most commonly at the proximal
hole of the distal interlocks
Intramedullary nail failure

IM nail removal
It

is not necessary to remove a nail in a

weight bearing limb unlike a plate. If
needed can be removed after 18
months. Indications for removal- Patient
request, pain swelling secondary to
backing out of the implant.

IM nail removal contd

Nail

removal should not be undertaken

lightly specialized extraction equipment
fitting the nail must be available. Full
weight bearing can commence
immediately after the removal of nail

Future direction
Nails

constructed of biodegradable
polymers will provide temporary
stabilization of fractures without the
potential long-term effects of a retained
foreign implant. Nickel-titanium shapememory alloys may enable the
development of implants that can change
shape as they warm to patient body
temperature..

Future direction contd

These

implants can improve stability as

they change shape after insertion and
recover curvature as they warm. IM nails
coated with biologically active agents,
such as bone morphogenetic proteins,
could help diminish nonunion rates,
while nails coated with antibiotics could
potentially limit postoperative infection

References
The

Elements Of Fracture Fixation

Anand Thakur Campbell s operative
orthopedics Canale Beaty Interlocking
nails - Rana Matthew R et al

References contd
Intramedullary

Nailing of the Lower

Extremity: Biomechanics and Biology -J
Am Acad Orthop Surg 2007;15:97-106
Historical overview and biomechanical
principles of intramedullary nailing ztok
A. Pilih , Andrej retnik

 Thank

You.