383MEDULLARY NAIMNG

Medullary NailingDURING the second half of the late war orthopaedicsurgeons in Britain and Western Europe began toencounter, among prisoners repatriated from Germany,fractures which had been treated by inserting a

steel nail throughout the length of the marrow cavity.This method, originally described by KuNTSCHERat the Vienna Surgical Congress of 1940, had beenreceived in Germany with early coldness and later

enthusiasm, and the published reports on it had beennoted here with some scepticism, but it was thenseen to be a practical success. Now that the best

part of a decade has elapsed, intramedullary nailingis routine in many German centres, where it wouldbe unusual not to treat a fresh fracture in this way.The latest edition of BOEHLER’S famous textbook 2

includes a special volume on the applications of thetechnique. The textbooks of SOEUR 3 and Roel-I]ER 4

witness its adoption in Belgium and France, andWESTERBORN 5 has described results obtained inScandinavia. But in Britain and the U.S.A. surgeonsare still slow to accept it, and little more than anoccasional case-report is to be found in the journals.It is not as if the principle of axial control were new.The intramedullary bone peg is an old-and usuallyinefficient—friend ; LAMBOTTE,6 before the firstworld war, experimented with the clavicle and otherbones, as later did that versatile surgeon HEY GROVES.More recently, LAMBRINUDI7 used central Kirschnerwires for stabilising difficult fractures of the forearmbones. The issues may be stated somewhat as follows.

In post-war Europe, with its shortage of hospitalbeds and materials and lack of skilled aftercare and

chemotherapy, the advent of the Kuntscher nail wasenormously advantageous. Patients could be senthome after a week or two, usually without plastersplintage, and often returned to light work after amonth. Physiotherapy was unnecessary when, for

practical purposes, the fracture had been abolishedat the outset of treatment. Of BOEHLER’S threefamous tenets of absolute reduction, absolute fixa-tion, and maximum function, it was for the surgeonto achieve the first, and the insertion of the right-size nail provided the second and permitted the last.In Britain and America a different situation, witha sufficiency of penicillin and good-quality metalappliances for internal fixation, accounted for thehesitant attitude towards the new method. When

open reduction was necessary, vitallium plates andscrews of known performance were used. Deliberate

leisurely open bone operations, protected by chemo-therapy and transfusion on the scale the war had madepossible, still seemed promising enough - to make

.

surgeons reluctant to contemplate quite a differenttechnique.. But plates and screws have their dis-

advantages. They impose mechanical conditionsat the fracture site with which the osteoblasts mustcomply or the technique will fail; and they may nullifythe longitudinal compression forces essential to sound1. Bull. War Med. 1943, 4. 16; 1944, 4, 333.2. Boehler, L. Technik der Knochenbruchbehandlung im Frieden

und im Kriege. Vienna, 1944.3. Soeur, R. L’osteosynthèse au clou. Brussels, 1946.4. Rocher, C. L’enclouage medullaire. Paris, 1945.5. Westerborn, A. Ann. Surg. 1948, 127, 577.6. Lambotte, A. Chirurgie opératoire des fractures. Paris,

1913.7. Lambrinudi, C. Proc. R. Soc. Med. 1940, 33, 153.

union. Hence the various stratagems-the coaptorsof DANIS, 8 and the slotted plates of EGGERS 9-

designed to allow the biological element in union fullplay. The Kuntscher nail, on the other hand, is anaxial rod on which the bone fragments are threadedand which converts all the forces of weight-bearingand muscle spasm into longitudinal compressionat the fracture gap.The technique and its applications vary in different

hands. Where KUNTSCHER and his colleagues woulduse the nail for almost every closed fracture in adults,others reserve it for difficult cases. On p. 387 inthis issue Mr. FRAENKEL describes the standardmethods used at Schleswig and Kiel, where a " closed "technique is usual, the fracture being reduced bytraction and the nail inserted through a stab over oneend of the bone under fluoroscopic control. K-UNTSCHERhimself never exposes the fracture, abhorring theperiosteal reflexion and fall in local pH which setback healing ; and if closed methods fail he resortsto old-fashioned traction or plaster. Other surgeonsdo not hesitate to perform open reduction and tointroduce the nail at the fracture level by a retro-grade method. At some clinics no external splintageis used, whereas at others a plaster cast gives thesurgeon a good night’s rest.The clinical, functional, and economic advantages

of nailing are so obvious that we may reasonably payparticular attention to its disadvantages and to theminority of failures. As MCFARLAND 10 has said-and it cannot be repeated too often-" the fracturepatient should be at least no worse off after treatmentthan if left alone ; he should be positively bettertreated than untreated ; operation should leave himin a better state than non-operative treatment ;and the added risk of operation-a real one-shouldbe commensurate with the added benefit." The

sepsis-rate in the great mass of German nailingoperations is somewhere in the region of 5%,11 afigure which, while acknowledging our own imper-fections, we must regard as 5% too high. But

against this, those who nail regularly regard infectionas a nuisance but not a menace. It does not leadto a general osteomyelitis, and the nail must notbe removed, for its splinting action is now doublyimportant and it drains the pus to the surface at thesite of introduction, where simple drainage of thesoft parts may be all that is needed. Fat-embolismseems to be mainly a theoretical danger, exceptperhaps in the femur ; SoEUR records only one casewhere it possibly occurred. Does the nail hindercallus formation ? Apparently not ; in KÜNTSCHER’Sfamous animal experiment, the insertion of a nailinto an intact bone provoked ensheathing callusformation in the absence of any fracture. The

question of X-ray control is a major one. The freeuse of screening makes nailing a rapid ’and trivial

operation, but the hazards are too serious to be

ignored. As SoEUR advises, it should be abandonedin favour of repeated radiography as for the insertionof a Smith-Petersen pin, a deliberate, often tedious,and major operation. It is obvious, too, that there8. Danis, R. At 12th Congress of the International Society of

Surgery. Lancet, 1947, ii, 520.9. Eggers, G. W. N. J. Bone Jt Surg. 1948, 30A, 40.

10. McFarland, B. At B.M.A. Annual Meeting, section oforthopædics. Lancet, July 10, p. 68.

11. Le Vay, A. D. At B.M.A. Annual Meeting, section oforthopædics. Brit. med. J. July 17, p. 158.

384 PENICILLIN IONISATION THERAPY—INDUCEMENT FUND

is no place for the occasional nailer, any more thanthere is for the occasional surgeon in any field, andthe new method should be tried only at the largefracture centres in this country. It is being so tried,and the first reports will be awaited with interest.Finally, the purely orthopaedic applications of the

intramedullary nail must not be forgotten, for inarthrodeses, osteotomies, and bone-lengthening andbone-shortening procedures of all kinds, KÜNTSCHERhas shown that it has a place of great value. Hereis a field for experiment open to every orthopaedicsurgeon.

Annotations

PENICILLIN IONISATION THERAPY

LOCALISED infections of surface tissues are now

commonly treated by simple topical applications of

penicillin ; but the not-infrequent failure of this methodhas caused the depth of penetration and degree ofabsorption to be questioned, and Sophian has shownexperimentally that tissue penetration is very super-ficial and absorption slight. Iontophoresis has been usedin the hope of overcoming these difficulties but therehave been conflicting reports on its effectiveness, andHamilton-Paterson 2 has obtained results which seemedto show that penicillin salts are poor conductors or

non-conductors of the electric current. Moreover,Popkin 3 was unable to demonstrate penicillin in theblood of patients treated by penicillin applied to the skinby iontophoresis.

Recently, Pereyra 4 has compared the specific-conductivity curves of penicillin G and crude sodium-penicillin extract with those of ’Mecholyl’ (acetyl-&bgr;-methylcholine) and sodium salicylate, both commonlyused in iontophoretic treatment, and with sodium chloride,a highly ionising inorganic salt. The crude penicillin wasa better electrical conductor than stock sodium peni-cillin G, and when used in the right concentration waslittle inferior in this respect to mecholyl chloride or

sodium salicylate. Thus, Hamilton-Paterson’s inabilityto demonstrate conduction in his experiments mayhave been due to the low concentrations of penicillinemployed-namely, 25-50 units per ml. Pereyra pointsout that 8000 units per ml. of sodium penicillin G or 5000units per ml. of crude sodium-penicillin extract givesa penicillin concentration of 0.5%-a strength at whichsatisfactory results are obtained from mecholyl chlorideand sodium salicylate. This concentration of penicillinis well tolerated by the skin and mucous membranes ;and Pereyra found that the application of solutionsin a glass chamber was more effective than by the moreusual gauze-pad technique.

Absorption with iontophoresis was compared with thatfrom ointments rubbed into the skin of the antecubitalarea for 15 minutes. Blood was withdrawn from the veinof the opposite arm at intervals up to an hour aftertreatment, and urine was collected for 2 hours. Afterneither inunction nor iontophoresis could penicillin bedetected in the blood ; in the urine, however, penicillinappeared within 15 minutes of iontophoresis. The

presence of this urinary penicillin was found to dependon the application of the negative electrode only to thesolution ; it was estimated that the skin transference ofpenicillin was at the rate of about 1 unit per sq. cm. ofskin per minute. The alkalinisation of the solution bythe current, using 5 milliamperes for 15 minutes, causedno appreciable destruction of penicillin. To limit this

1. Sophian, L. H. Amer. J. med. Sci. 1944, 208, 577.2. Hamilton-Paterson, J. L. Brit. med. J. 1946, i, 680.3. Popkin, R. J. J. Amer. med. Ass. 1946, 132, 238.4. Pereyra, A. J. Nav. med. Bull., Wash. 1948, 48, 40.

alkaline shift, only distilled water should be employedfor dissolving the penicillin.The application of penicillin by iontophoresis thus

offers definite advantages over parenteral and simpletopical administration in the treatment of localisedsurface tissue infections ; the concentrations of penicillinachieved at the site of application much exceed thosepossible by the parenteral route. This has been endorsedby Pereyra and Laudy 5 who showed that penicillinwhen administered parenterally fails to heal chancroidulcers, but when applied locally by iontophoresis pro-duces prompt remission ; and a similar finding hasbeen made by Pereyra in a series of 13 cases.

INDUCEMENT FUND

EXECUTIVE councils have lately been seeking the viewsof local medical committees on the adequacy of generalmedical services in their areas. Account is being takenof the numbers of the population (including, naturally,those who have elected to seek medical advice privately)and of the doctors engaged in general practice as princi-pals or as assistants, together with any local social ortopographical features which might make the provisionof a medical service more than ordinarily difficult.Presumably the next step will be to try to attract

extra doctors to those areas found to be under-provided.In areas where doctors’ lists approach or exceed thepermitted maxima, they have the choice of curtailingthe acceptance of new patients or of arranging for addi-tional assistance. In such an area a newcomer shouldfind an immediate and growing income, which could beenhanced at first, if need be, by acceptance of the annualfixed payment. A greater difficulty, until the housingshortage has eased and health-centre building becomespossible, may well be the finding of suitable accommoda-tion in which to practise and to live. Elsewhere, andnotably in sparsely populated moorland areas, quitedifferent factors may hinder executive councils in

improving, or even maintaining, an already inadequateservice. It was for such areas that the inducement pay-ments were primarily intended ; and in a timely letterthe Ministry of Health reminds the councils of a fundfrom which such payments may be made. The moneyset aside for this purpose is equal to 1% of the totalcentral pool for the payment of general practitioners,but it comes from a separate grant and is not a chargeon the pool. This money is immediately available, andthe Minister intends that the first payments shall,wherever possible, be made by the end of the presentquarter. He therefore urges early action by execu-tive councils, in consultation with the local medicalcommittees, to assess and bring to his notice" any cases where they are satisfied that general medicalservices adequate to the needs of the district cannot beprovided, or cannot reasonably be expected to be maintained,without an inducement payment, and the amount of theinducement payment which they consider necessary to enablean adequate service to be provided or maintained."The council is reminded that mileage payments to ruralpractitioners are likely to be at least double thosereceived in the past, but that the special-subsidy portionof the old insurance mileage fund has ceased. From thisfund special payments used to be made in respect ofpatients to whose homes access was difficult ; it alsosubsidised heavy expenses such as those caused by thenecessary upkeep of scattered branch surgeries. Fromnow on such assistance will come directly from theinducement fund.The Minister’s letter suggests four other types of case

where inducement payments will probably be needed.The first is where a vacancy has been advertised but noapplications have been received ; but the receipt of oneor more applications for an advertised post should not

5. Pereyra, A. J., Laudy, S. Ibid, 1944, 43, 189.