Editorial comment: Symposium: femoral fractures: contemporary treatment approaches.

The introduction of intramedullary (IM) nailing of femoral shaft fractures revolutionized the treatment of these previously catastrophic injuries. Prior to this, patients hung in skeletal traction for weeks and were placed into spica casts with the hopes that the fracture would not shorten or angulate during this immobilization period. Patients lost productive time from work, experienced complications from bed rest, and often failed to obtain correct anatomic and mechanical axis alignment. During the Second World War, Gerhard Kuntscher experimented with a technique to place a cloverleaf shaped IM device in the femur to support these fractures until they healed. Initially, surgeons did not accept this technique, even in the German military, but he eventually won local praise for his care through early mobilization of these injured soldiers. Because of the war, though, this information was not disseminated beyond Germany. On March 12, 1945, Time [1] published an article entitled, “Amazing Thigh Bone”, which detailed the story of a US soldier treated by Kuntscher following his femoral shaft fracture while in Germany. Surgeons from the United States had no opinion on the care, but called it a “daring operation” [1]. The patient was pleased, and was able to walk around with a straight limb while other Americans with similar injuries were tied to hospital beds in traction. While most US physicians were skeptical, some visionaries embraced this technique. Much has changed during the last 70 years as we have refined this technique. Innovators developed interlocking nails, as the initial designs did not allow for axial or rotational control. Manufacturing changed from stainless steel to titanium, and the once slotted nails became closed-section nails. The operation is now commonplace, and the results are consistent. Techniques have evolved to allow cephalomedullary screw placement and a variety of acceptable insertion sites including trochanteric and intercondylar for retrograde nailing. Additionally, augmentation of femoral IM nails with blocking screws has allowed for extended indications for difficult fractures that previously would not be considered for this operation. The research questions now no longer pertain to whether nailing is an appropriate treatment for femur fractures — all agree that it is — but rather to the physiologic implications of IM nailing, both for the bone and for the trauma patient more generally. Other unsolved issues include deciding on the appropriate timing for IM nailing, choosing from among the available implants for particular fracture patterns, and further refining our surgical technique to ensure appropriate length, alignment, and rotation are still clinical problems that must be addressed by the surgeon. Kuntscher’s original piriformis starting point, large diameter IM nails, and inability to lock the fracture in position all have been modified with improved functional results. However, new questions have arisen since this amazing technique was introduced. What to do with pediatric patients? Reamed, locked IM nails are not an option, and elastic nails give the patient their best shot at healing this fracture during their school age years. And, finally, what are the best approaches for fractures that might themselves be the result of treatments that physicians have prescribed, such as bisphosphonates, and what medications and host factors might affect the healing of femur fractures, both positively and negatively. This symposium is intended to answer some of these questions while keeping the reader current and stimulating all of us to find ways to optimize patient care. We should be pleased with the progress we have been able to make as clinician-scientists in the treatment of femoral shaft fractures with IM nailing, but it is important that we continue to innovate. This is no time for complacency.