259 
CHAPTER VI. 
Osteotomy my means of marrow nails. 
A* General remarks. 
Osteotomy means, strictly speaking, a severing of the 
bone* It is most frequently performed, in cases of poorly 
healed bone fractures. The oper tive correction of a con- 
genital curvature falls under the same heading. But also 
the operative treatment of a bone fracture is in most cases 
called osteotomy. Accordingly, all these interventions are 
included in this chapter, during which the bone is exposed, 
severed, and re-joined, or if it was severed before, such as 
in case of poorly fixed fractures, or pseudarthroses, it is 
exposed and re-joined. 
For re-joining, we have many different contrivances a- 
vailable, such as wires, screws, plates, etc, but none of 
them^guarantees a really stable union. In any case addition-' 
al fixation is necessary by means of a plaster cast or splint, 
or oven the use of the extension method in some cases. The 
insufficient mechanical stability of the osteosynthesis ob- 
tained by the use of these contrivances arises from two 
causes: 
These contrivances have been constructed too weak so 
that they cannot stand the strain they are exposed to, and 
their fastening becomes loosened by the resorption of the 
bones. The strain exerted by osteosynthesis is equal to 
that of the normal bone, as described in detail in chapter 
III. It is produced by the muscular strength and amounts 
to enormous figures, since, when a bone is severed, the 
whole cross-section of the musculature works in the same 
direction, so that, in this case, the usual antagonists, 
flexors and extensors, adductors and abductors cooperate. 
For this reason, the extension forces and the pressing 
forces will amount to several hundred kilograms. The form 
of the strain tends to produce angulation. With the osteo- 
synthesis, it manifests itself as an angulation at the 
place of osteotomy. 
For this reason it is natural to use marrow nails also 
during osteotomy, since it is the marrow nail alone, which 
is capable of resisting these forces without any additional 
plaster cast or traction, in order to obtain thus a really 
"stable osteosynthesis". 
The author accordingly has some osteotomies even a- 
mong his first marrow nailings. If the method is used in 
this form, however, the great advantages of marrow nailing 
for simple fractures as described in the preceding chapter 
are not all present to the same extent. This results from 
the fact that the injury of the bone is exposed. This al- 
ways involves a considerable increase of the danger of in- 
fection, damage to the periosteum, as well as other dangers 
and disadvantages (see chapter IV). It will be demonstrated 
in particular that these dangers are less imminent in case of 
application of marrow nails than in case of the methods used 
previously though the indications for intervention by means 
of osteotomy must not be less strict than before. 260 
Indications for osteotomy. 
It is difficult to give exact directions for indica- 
tions for osteotomy* In the first place, much depends-on 
the skill and the experience of the individual surgeon, 
for osteotomy is one of the most difficult operations. 
This also applies if marrow nails are used. lust in this 
case, many technical details and special maneuvers must be 
observed. 
There is a great difference concerning the tendency 
for treating fractures operatively in the various countries. 
It is greatest in the United states, where ALBEEfs excellent 
methods have found many adherents. But even in Europe there 
are surgeons who treat up to 30 % of all fractures operative- 
ly. In Germany, one is much reserved, though, under the in- 
fluence of F. KOENIG and MATTI, one has given up the point 
of view that only those fractures should be treated operative- 
ly with which the conservative methods have failed. Chiefly 
owing to KOENIG’S merit, exact indications have been estab- 
lished, to the effect that only those fractures should be 
treated operatively which, when treated by conservative 
methods, yield poor results, as shown by experience. 
One must consider again and again that in case of opera- 
tive 'exposure of the fracture, the bone necessarily will not 
heal so well as without it, because of damage to the regenerat- 
ing bone, chiefly by injury of the periosteum and because of 
the danger of infection. Both involve a considerable delay, 
as demonstrated in chapters III and IV. Statistics also 
show that operated fractures need 2-3 times as much time 
for healing, which means a correspondingly longer fixation 
and injury to the joints. For this reason operation is suit- 
able only if other, greater disadvantages are avoided or re- 
moved by it. Not even the generous use of sulfonamides, can 
decisively decrease the danger of infection, but penicillin 
does effect it. We wish to demonstrate later that the use of 
marrow nails may also considerably decrease the disturbances 
of the regeneration of the bones resulting from damage to the 
periosteum. Herein lies the greatest advantage in the use of 
marrow nails during osteotomy, though the other advantages 
of marrow nailing exist as in case of simple fractures. These 
are: 
1. Absolute fixation of the fracture, and thus ideal me- 
chanico-biological conditions for the transformation 
of the regenerated tissue to osseous callus (see chap- 
ter III), it is both a good prophylaxis and therapy 
of infection. 
2. Absolutely ’’stable osteosynthesis”. Thus, the nail is 
not only a substitute for the contrivances used previous- 
ly (screws, plates, etc.), but the realization of an en- 
tirely new principle with all the immense advantages of 
early motion for the preservation of muscles, joints 
and circulation of the injured limbs, for the formation 
of callus, and the general condition of the body, and for 
the guarantee of the anatomical result of the operation. The greatest advantage, however, is the fact, as men- 
tioned above, that we may arrive through use of marrow nails, 
at an entirely new principle of osteosynthesis, that of the 
greatest possible conservation of the periosteum as far as 
the damage to the regenerating bone is concerned. 
This requires an entirely new technique. It is empha- 
sized on purpose that we may arrive at this principle: Of 
course, one can as well perform marrow nailing osteotomy 
according to the former technique with extensive separation 
of the periosteum from the bone and even severing of the con- 
nection with the soft parts. But in that case, one sets a- 
side this important advantage. This separation is inevitable 
for the fixation making use of LANE's plates or a wire splint. 
If we use marrow nails, however, we can desist from this old 
principle of VON LANGENBECK's subperiosteal operation. It 
has been shown in chapter III, that the periosteum has the 
principal share in the regeneration of the bones, and BARTH'S 
and the author's experiments have been mentioned, according 
to which periosteal osteogenesis will occur to its full ex- 
tent only if the periosteum closely adheres to the bone. So 
it is of the utmost importance for the formation of callus 
that the periosteum is not detached at all. In addition, 
the periosteum forms the most important blood supply of the 
outer compacts layers of the bone. For this reason, detach- 
ing the periosteum involves a serious damage to the blood 
supply of the bone and thus to its power of resistance a- 
gainst infection. This is certainly one of the reasons why 
osteotomies are so easily infected. Lastly, detaching the 
periosteum involves a considerable increase of the injured 
area, which increases the danger of infection as well. 
As mentioned in chapter III, the necrotic or neorobiotic 
bone is truly a strong stimulus for the regeneration of the 
bone. This is, according to LEXER, the advantage of the sub- 
periosteal operation; though, during this operation the peri- 
osteum must be detached very cautiously and together with the 
surrounding muscles, which contain the most important vessels 
for the periosteum. The nail in its marrow cavity, however, 
can produce a stimulation at least equally strong without 
the periosteum being detached, as the author was in a position 
to show (see chapter III). As mentioned before, the necro- 
biotic bone can only be effective if the periosteum closely 
adheres to the bone. If this is not the case, the inter- 
stice will be filled with coagulated blood. The osteogenic 
cells first have to force their way through it and reach the 
bone, according to BARTH, only with difficulty or too late. 
The most unsatisfactory kind o f osteotomy doubtlessly is the 
transperiosteal one, i.e, exposure of the bone covered with 
periosteum from the soft parts with subsequent detachment of 
the periosteum from the bone, for then, the periosteum and 
the bone are deprived of the greater part of the supplying 
vessels. 
With the use of marrow nails, it is possible in most 
cases to leave intact to a large extent the connection of 
the periosteum with both the bone and the surrounding soft 
parts (see illustration 129)• Illustration 129. 
Scheme of the osteosynthesis; 
a) subperiosteal osteotomy according to 
VON LANGENBECK- detachment of the peri- 
osteum from the bone 
b) transperiosteal operation - detachment 
of the periosteum from the bone and the 
surrounding soft parts 
c) marrow nail osteosynthesis according to 
KUENTSCHER - leaving intact the connection 
of the periosteum with both the bone and 
the surrounding area. This-requires a special way of proceeding during osteo- 
synthesis, which is quite different from the usual procedure* 
Operations have been performed in this way before, for in- 
stance during the oblique subtrochanteric osteotomy accord- 
ing to HOFFA, but they were limited to occasional exceptional 
cases. They were always osteotomies and never osteosyntheses* 
The HOFFA osteotomy rather renounces synthesis, and the bone 
ends are held together by the surrounding soft parts. But 
the connection of the periosteum with the soft parts and the 
bone is left absolutely intact, since only a small incision 
of the skin is made, into which the chisel is introduced and 
pushed through the soft parts to the periosteum. Then, peri- 
osteum and bone are severed together at the same time. On 
principle marrow nail osteotomy is performed in a similar way, 
only it is followed by marrow nail synthesis. This method 
is applicable to all long tube bones. Of course, the small 
incision as made during HOFFA’s osteotomy will do only in a 
very few cases, though the incision of the skin is in most 
cases considerably smaller than with the former osteoynthesis, 
for the site of osteotomy need not be exposed in all direc- 
tions and over a large area as for instance in the case of 
application of Lane’s plates. Nor is it necessary to remove 
the callus which may happen to exist, which is required when 
Lane’s plates are used. It is sufficient to sever the frag- 
ments; the masses of callus are left intact, for the peri- 
osteum usually adheres particularly closely to them and, be- 
cause of the numerous cracks and fissures of the callus mas- 
ses, the periosteum can hardly be detached, at least half 
will be undamaged. The callus masses, being valuable build- 
ing material, form the new callus on the spot. We wish to 
illustrate this by 2 examples: 
Two years ago, patient S. sustained a gunshot fracture 
of the left thigh at the border of the upper third, which 
healed in marked adduction, with 5 centimeters shortening. 
There was still a fistula when the nail was applied (see 
illustration 130c). A $ cm. long incision of tie skin was 
made on the lateral side of the thigh. At that place, the 
tip of the proximal fragment could be observed under the 
skin. After the incision it was observed that the tip was 
still covered by a layer of muscles \ - 1 cm. thick. These 
muscles were left completely intact above the proximal end. 
Starting directly at the tip, the muscles were bluntly split 
by two raspatories distally for about 3 cm. The marrow oav-' 
ity of the proximal fragment could now be opened with an awl, 
which was easily performed. Then, a 3 cm. broad chisel was 
obliquely applied'in the direction of the inner edge cf the 
proximal fragment, as shown in illustration 130 b. Then, 
the two fragments were separated by one blow and the marrcw 
cavity of the distal fragment was drilled open in the same 
way, as the proximal one. The marrcw nail was now driven 
in as described later in this chapter. The periosteum was 
everywhere left practically intact during this operation. 
Its connection with the bone and the soft parts was broken 
nowhere. Not the slightest piece of callus was removed. 
After the operation, the masses of callus lay almost as 
close to each other as in case of a month old fracture. The 
shortening was completely corrected. The operation lasted 
12 minutes. 264 
a be 
d e 
Illustration 130* 
a) Patient S. 2 year old healed gunshot 
fracture of the femur with fistula, 
marked angulation of the axis and 5 cm. 
shortening. 
b) Diagram of the incision of the skin and of 
the direction of the severing of the callus 
with a chisel. No piece of callus was removed, 
the periosteum everywhere remains in connection 
with the bone and the surrounding muscles. 
c) After marrow nailing immediately after the 
operation (with drainage). 
d) After 10 weeks. 
e) After removal of the nail, 16 weeks after the 
operation. If a 8 cm. long Lane's plate had been applied, a con- 
siderable part of the periosteum and callus would have had 
to be-removed, as is shown schematically in illustration 
131. 
Of course, the method 
of operation will vary in the 
individual cases, but the 
principle is always the same# 
It is nearly always possible 
to approach the place of the 
bone fracture or of the in- 
tended osteotomy by mere 
blunt separation of the mus- 
cles, though it must be ad- 
mitted that the survey is 
often less clear than in 
case of extensive detachment 
of the periosteum, which of- 
ten complicates the operation. 
Quite palpable or visible bony 
protuberances, etc., which 
are marked in the X-ray as 
well, are then used as clues, 
such as the pointed end of 
the proximal fragile nt in the 
above mentioned example. On 
the other hand, e.g. in case 
of an old fracture, the nail 
can be driven in if only a 
very narrow area around the 
fracture cleft is seen. If 
the fracture is not yet quite 
fixed by bony healing it is 
very often possible, even 
with the femur, to break the 
fracture apart by powerful 
bending. It is suitable to 
do this immediately after the 
incision of the skin. For 
this purpose, and to facili- 
tate reduction, a 2 cm. long 
piece of the fibula is re- 
sected in the lower leg in 
every case. This is neces- 
sary as well for the mechani- 
co-biological reasons men- 
tioned above (see chapter III)# 
Resection of the fibula. 
On principle it is of no importance where this resec- 
tion of the fibula is performed; whether in the upper or 
lower third or in the middle. It is not suitable to per- 
form the resection at the very level of the fracture, for, 
if an infection of the place of resection occurs, the place 
of fracture is endangered as well. In case of resection in 
the upper third, the peroneus is endangered. The effect of 
the resection is considerably decreased, however, if the 
Illustration 131, 
Diagram of the same fracture 
as in illustration 130, in 
order to show how much callus 
and periosteum would have had 
to be removed, if the fracture 
was treated with 8cm. long 
Lane’s plates. fibula is severed at some distance from the fracture, i.e. 
both bones are rather tightly mechanically coupled to each 
other.' The resection is performed best by a longitudinal 
incision at the outside of the lower leg. The fibula is 
easily palpated through the skin in most cases. The mus- 
cles above the bone are bluntly separated, and then the 
periosteum connected with the muscles is scraped off the 
fibula. The muscles are then kept apart by 2 raspatories, 
introduced deeply. If the fibula is thin and delicate, 
it can be easily severed with a pair of rib-scissors. 
With stronger fibulae this is impossible, and then it is. 
the simplest method to perform the resection with a chisel, 
cutting out a wedge at the proximal and distal ends of the 
place of resection. The fibula will easily splinter, so 
the last few points and jagged ends must be removed with 
Luerfs rongeurs. During the operation, some of the numer- 
ous deep veins of the calf may be injured and often they 
bleed violently. In most cases, the hemorrhage will be 
stopped by pressure and is best controlled by ligation. 
It is always suitable to insert a rubber drain during the 
first 24, at most (J) 48, hours, in order to drain the 
hematoma. This is urgently recommended for all other osteo- 
tomies and operative openings of bone fractures as well. 
It must,'by no means, be forgotten to remove this drain in 
due time, since otherwise an infection of the wound will oc- 
cur almost without fail. 
In case of a fracture of the femur healed with shorten- 
ing, it is also very often possible to detach the two frag- 
ments by the lever effect of a powerful raspatory introduced 
between them. It is also frequently sufficient to sever the 
callus partially with a chisel, the rest will break during 
the flexion. In case of pseudarthroses too, it is sufficient 
in most cases to cut open one side of the solid capsule of 
connective tis-sue with a knife. Then, one can break the 
pseudarthrosis open. 
After the severing, the surfaces of fracture need only 
some smoothing so that they fit well upon each other and, 
if necessary, the marrow cavity must be drilled open. All 
lateral spicules and protuberances of the extra-callus are 
not removed, in order to avoid any avoidable damage to the 
periosteum and any unnecessary destruction of tissue and 
hemorrhage. It will rarely occur that such a callus spicule 
impedes the establishment of ideal resection. If so, it 
must be removed of course. 
If the poorly healed fracture is som$ years old. chisel 
and saw must be used. Even in this case it is only important 
to bore open the marrow cavities on both sides and to get 
planes fitting to each other tolerably well. The position 
of the planes depends on the position and course of the old 
fracture planes. If a transverse fracture is involved, the 
2 sawed surfaces of the fragments must be perpendicular to 
the axis of the marrow cavity, so that the ends fit as well 
as possible after the insertion of the nail. Accordingly, 
oblique sawed surfaces are made in case of an original ob- 
lique fracture. These sawed surfaces should pass through 
the intact periosteum at the place of the original fracture, 
so that the attached caps of callus are sawed from the ends of the fracture. These then form broad support flanges at 
the place of junction, which considerably contribute to a 
rapid and certain healing. The surfaces must not be located 
too high nor too low, lest the operated leg becomes shorter 
or longer, as is shown in illustration 132. 
a b 
Illustration 132. 
Diagram of the marrow nail osteosynthesis 
of a fracture of the femur healed with 
marked shortening and angulation. The lo- 
cation of the sawed surfaces is marked with 
little lines, the chiseled surface is dotted, 
a) before marrow nailing 
b) after marrow nailing 
At the place of osteotomy, a broad flange has been 
formed. 
It must be observed that a piece of the bony mass is 
often resorbed at the outside so that a small defect will 
remain after the osteosynthesis. These sawed surfaces u- 
sually open the marrow cavities, or render their opening 
easy. The sawed surfaces being made, the fragments are 
separated with a large chisel in the direction of the for- 
mer margin of the compacta between the fragments. In il- 
lustration 132 one has to imagine the chisel applied in the 
direction vertical to the perspective plane, on the dotted 
line. 
Only in particularly favorable developed cases are com- 
plicated osteotomy planes like that possible, and they re- 
quire an extensive exposure at the osteotomy site. For this 
reason, one can make the operation easier at the upper ex- 
tremity by resecting the whole place of the fracture and by 
forming the fracture ends in a suitable shape, since length 
is not so important with the upper extremity. The union is 
performed according to the same principles as with the pseu- 
darthrosis, which will be described in particular in this 
chapter. The splintering up of the ends has proved suitable 
as well, the splinters then remain in connection with the 
periosteum and the muscles. 
With the lower extremity, however, any shortening must 
be carefully avoided. During all osteotomies, it is inap- propriate to prolong the operation. So it will often oc- 
cur that one has to desist from the establishment of the 
described exact and broad contact, which may usually be 
done without concern in case of marrow nailing. Even here, 
the favorable healing conditions of the method promise sa- 
tisfactory results. 
At this point, it is remarked that the femur and hu- 
merus show a considerably greater power of regeneration than 
the bones of the lower leg and the forearm. 
As an example for such an osteosynthesis with insuf- 
ficient contact, we mention 23 year old B.K. 3 years ago, 
he sustained a gunshot fracture of the right femur at the 
border of the lower third. Treated with plaster cast. An 
almost complete stiffening of the knee-joint occurred, while 
the fracture was fixed in a favorable position. • Because of 
persistent fistulae maintained by sequestra within the bone 
a considerable part of the outer wall of the bone was eroded 
away. The remaining part of 
the bone was markedly ebur- 
nized, and during a walk, it 
broke as a fatigue fracture 
with a typical transverse 
cleft with smooth surfaces 
(see chapter III). After the 
war, this type of fracture 
has been frequently observed, 
as this operation of "sauceri- 
zation" has often been per- 
formed (principle of removal 
of an osteomyelitic cavity 
according to NEUBERT, Kiel). 
These fractures are very dif- 
ficult to heal in plaster 
casts (see illustration 133) • 
Marrow nailing was per- 
formed although a fistula ex- 
isted (see chapter VII)* In 
order to avoid a considerable 
shortening, the bone ends 
could not be prepared to fit 
exactly. For this reason, 
the roentgenogram made imme- 
diately after the operation 
shows marked defects at the 
osteotomy site since so much 
bone had been lost by sauceri- 
zation. In spite of that, an 
excellent healing result was 
obtained. The gaps were 
filled because of a suffi- • 
cient development of callus. 
The course of healing was 
without any complications. 
No plaster oast was applied. 
The patient, however, got up from bed and used his leg only 
4 months afterwards. After 3 more months, the nail was re- 
moved (see illustration 134)* 
Illustration 133• 
Fatigue fracture after "sauce- 
rization" of 3 year old gun- 
shot fracture of the right 
femur of 23 year old B. K. 
the bone is markedly ebur- 
nized at the place of frac- 
ture . 269 
Illustration 134* 
The same patient B.K. as represented in 
illustration 133, immediately after the 
marrow nailingj 
a) the bone ends do not fit well, since a 
marked shortening had to be avoided. 
b) The gaps are completely filled with cal- 
lus 4 months afterwards so the patient 
can use his leg. 270 
The stability of the osteosynthesis, which is so im- 
portant as regards bridging over by bones and control of 
infection, is equal in these cases, if the nail is driven 
in both marrow tubes. If this is not possible, the cases 
with exact adaptation of the fracture ends and the masses 
of callus are more favorable. One might even perform an 
additional fixation using a plaster cast or splint. On the 
whole, the principles for the establishment of absolute 
stability with simple fractures apply here as well (see 
chapter V). 
In addition, complicated sawed planes have the disad- 
vantage that the periosteum is more seriously damaged and 
that it peels off at the edges of the sawed surfaces despite 
all care. Only with soft callus is it suitable to use a 
chisel. With brittle bones, there is the great danger of 
their splintering. This is a great trouble especially in 
case of’marrow nailing, for the cracks will always run along 
the shaft and thus force open the marrow tube, so the nail 
is not held firm. 
For this reason, only the saw can be used in most cases. 
The author has never used the Gigli-saw. It easily causes 
damages to the periosteum, endangers the soft parts, and, 
moreover, often breaks. Even a good wire-saw is not capable 
of severing a hard femoral shaft transversely, nor an ebur- 
nized bone. The electrically driven circular saw is hazar- 
dous, since it will easily slide off the bone and may cause 
serious injuries of the soft parts; so it must be held firm 
with both hands. The best saw is the bow -saw. It may be 
used in many ways, even cross-section cuts may be made even 
of the femur, if the patient 
is not too fat, since the in- 
cision of the skin is always 
performed at the outside in 
case of a marrow nailing os- 
teotomy. There is only a 
thin coat of muscles. These 
are held apart by raspatories 
or the very practical Hohmann- 
hooks (see illustration 135)* 
This cross-section saw- 
ing is considerably easier 
when the fracture healed with 
angulation. One often need 
only keep the skin away from 
the fracture (see illustration 
136) . 
With the bow-saw, the fit- 
ting of the fracture ends can 
be effected very easily. The 
extremity is put to a sharp an- 
gulation, so that the ends 
approach the wound, then they 
can be easily sawed. In the 
demonstrated example of the 
ulna, both ends can be easily 
shortened with the saw, so 
that they fit again with ob- 
Illustration 133* 
Severing of a femur with the 
bow saw, starting from a long 
incision of the skin at the 
outside. The muscles are kept 
apart-by raspatories. Trans- 
verse sawing. liquo planes (see illustra- 
tion 137) . 
During transverse saw- 
ing the bone is not wholly 
• exposed according to the a- 
bove mentioned principles. 
It is still covered by a 
layer of muscles about J - 
1 cm. thick. This layer is 
severed with a knife at the 
place of sawing in the plane 
of the section. If the bone 
ends are shortened, the peri- 
osteum is pushed back to the 
sawed surface, so it is pre- 
served. The bow-saw enables 
us to shape the bone ends in 
other forms, such as the step- 
like freshening of pseudar- 
throses. After sawing the 
bone transversely, longitudin- 
al cuts of the desired length 
are first performed on both 
bone ends in this case, then 
the transverse sections are 
made over them. 
If the bow-saw is used 
during transverse cuts, how- 
ever, a very long incision 
of the skin is always neces- 
sary, so one advantage of mar- 
row nailing is lost. For this 
reason, the author described 
in 1944 a saw which permits 
to perform this cutting from 
a very small incision of the 
skin. This is the counter- 
incision saw. The bone is 
exposed as described at the 
place of operation, then a 
bullet-forceps is pushed 
through the muscles past the 
bone, before or behind it, 
a method which is known to 
every surgeon from thousands 
of operations for the intro- 
duction of a rubber drain in 
case of suppurating processes. 
This incision need not be ex- 
actly opposite the operative wound, but according to the lo- 
cation of the bundles of vessels and nerves, may be performed 
more to the front or to the back. The incision over the point 
of the forceps need only be 1 - lg cm. long. No rubber drain, 
but a thin metal tube is now introduced. Two wire loops are 
fixed to its end in the operative wound, they are drawn from 
the operative wound, one before, the other behind the bone. 
One loop is held by the operating surgeon, the other by the 
assistant. The saw-blade is now introduced into the metal 
tube. The blade is provided with a small piston gliding to 
Illustration 136. 
Severing of an ulnahealed 
with angulation with the 
bow-saw. Oblique sawed sur- 
faces. 
Illustration 137« 
Shortening of the bone frag- 
ments protruding from the 
wound after having be$n cut 
with the bow-saw. Oblique 
sawed surfaces are restored. and fro in the tube, thus protecting the tube from being in- 
jured by the blade. Then, the saw-blade is fixed to the bow- 
saw on both sides of the extremity. (See illustration 138). 
Illustration 13 
Counterincisioh-saw according to KUENTSCHEH. 
a) Performance of a counterincision 
b) after introduction of the metal tube. Both transverse and oblique cuts at any angle to the 
bone axis are easily performed with this saw from very 
small incisions of the skin without the slightest hazard 
of damage to the soft parts, for the muscles are safely 
kept away from the saw blade by the tube. Since its end 
is firmly pressed on the bone by the wire loops, no soft 
parts may slip in between the tube and the bone. These 
loops keep the wound open and prevent any injury of the 
soft parts in the operative wound, so no other hooks are 
necessary in the wound. The metal tube is able to follow 
any change of the inclination of the saw-blade in relation 
to the longitudinal axis of the bone. In aseptic cases, 
the counterincision is closed again immediately after the 
saw is removed. In septic cases, the tube is replaced by 
a rubber drain, if necessary. The saw can be used both 
with thin forearms and with the thickest femurs. 
A severing without splintering from a comperatively 
small incision of the skin may also be performed with the 
electric drill. A number of holes are bored in the in- 
tended line of separation, which are then joined to each 
other by the chisel. This method takes up much time and 
involves the hazard of a necrosis of the bone through heat- 
ing at the place of drilling. 
It must be the objective of every operative technique 
to reduce to a minimum all injuries of the tissue and nec- 
roses, since they impair the conditions of healing and in- 
crease the hazard of infection. For the same reason, one 
should keep the incision of the skin as small as possible. 
But this must not complicate the operation and thus pro- 
long it, for a longef operation involves the same dangers 
by drying of the wounds, possible infection from the air, 
the operator’s hands, etc. In addition, there are the ha- 
zards of constant loss of blood and of shock in case of 
large wounds. All this applies in particular to osteotomy. 
In chapter I, these hazards and disadvantages of an 
operative treatment of the fracture have been described in 
detail. By experience, the most careful asepsis, and a 
good technique, one may avoid them or reduce them to a large 
degree, particularly by using marrow nails, because this 
method permits joining the fragments without considerable 
damage to the soft parts and to the periosteum and because 
this operation may be performed in considerably less time 
after some practice. But it must also be possible to finish 
the first part quickly, for really serious dangers or even 
death by shock will only occur if the operation lasts too 
long. This has been discussed before in chapter IV. Prac- 
tically, it is only the osteotomy of the femur which is 
hazardous in this respect, for here really great difficul- 
ties have to be overcome in case of old fractures. The frac- 
ture ends are imbedded in the midst of thick muscles, and 
though cicatricial tissue grows luxuriously around them. 
In addition, considerable hemorrhages complicate the oper- 
ation considerably in this area. Vision is considerably 
impaired by the irregular form of the callus, and it is, 
besides, hardly possible to separate the cicatricial tissue 
from the callus. Together with the shortening of the mus- 
cles , the cicatricial tissue makes-reduction extremely 274 
difficult. For this reason, even an experienced orthopedic 
surgeon often requires several hours to perform the opera- 
tion. But this must be avoided if possible and one cannot 
warn against this urgently enough. The author recommends 
in such cases that the osteotomy be performed in two oper- 
ations. Why should this principle, so successful in ab- 
dominal surgery, not apply to certain cases of bone surgery 
as well? In addition, there is only a small number of these 
cases. In case of such a complicated osteotomy of the femur, 
one might, for instance, perform the operation to the point 
where the osteotomy site is clearly demonstrated. Then, the 
operation is interrupted after carefully controlling the 
hemorrhage and the skin is sutured. If necessary transfusions, 
infusions, etc. can be now administered. 8-10 days later 
the wound is reopened, and the cutting of the bone, reduction 
and marrow nailing can now be performed at once. With this 
method, however, a considerable delay may be occasionally 
caused by an infection subsequent to the first operation. 
But even in this case the jjatient has been certainly saved 
from a more serious inconvenience, viz. an infection of the 
bone wound. 
B. Technique of marrow nailing during osteotomy. 
During osteotomy the introduction of the nail is much 
more simple than in the percutaneous nailing of a fresh 
fracture (chapter V)• 
The marrow cavity is opened, and the nail is intro- 
duced under direct vision. It is unnecessary to use the X- 
ray, it may be used at the end of the operation, to control 
the result. In case of poorly fixed fractures, the marrow 
cavity is open already, in the rest of the cases, it can be 
easily opened with the awl, which, causing no heat-necroses, 
should be preferred to the electric drill. The electric 
drill is of a complicated structure and may even fail some- 
times, though in some oases of old pseudarthroses it is oc- 
casionally necessary to use it. In these cases, the marrow 
cavity is often closed by hard ebarnized bone several centi- 
meters in length. With the lower leg, upper arm, and fore- 
arm, the nail is then introduced from a place outside the 
fracture as in case of percutaneous marrow nailing and is 
visible in the wound in the marrow' cavity of the one frag- 
ment. It need only be introduced into the marrow cavity of 
the other fragment, then the nail is driven in finally. Thus, 
the osteosynthesis is accomplished. 
In case of operations of the femur, it is recommended 
to lay the patient on his side on his sound leg. Then the 
incision of*the skin is located" on the lateral aspect, which 
affords a convenient approach to the bone without endangering 
large vessels.' The metal guide rod is introduced into the 
opened marrow cavity of the proximal fragment and pushed up 
to the top of the trochanter major, where it easily pierces 
the very thin compacta of that area with a perceptible jerk. 
Its point is then palpable under the skin of the buttocks. 
This point is exposed by an incision of the skin 1 - Ij cm. 
long. The nail is now pushed on this point and driven in, 
until it protrudes about | cm. from the marrow cavity of 
the proximal fragment (see illustration 139). a b 
Illustration 139. 
Technique of marrow nailing during an 
osteotomy. 
a) Introduction of the guide rod into 
the osteotomy wound, its point is 
palpable through the skin and is ex- 
posed by a stab incision, 
b) the marrow nail is pushed on the guide 
rod and driven in. 
In most cases, it is possible even with the femur to 
place the bone fragments on each other and to drive the 
nail in the distal marrow cavity. If the patients are 
robust and have a shortening due to an old poorly healed 
fracture, not even considerable pulling by means of an ex- 
tension apparatus can correct the shortening. In addition, 
these femurs usually are in a varus position, but after 
cutting the bone at the old fracture site it is always 
possible to place the fragments on each other by angulation. 
The apex of this angle is lateral, that is out of the wound, 
as shown by the diagram of illustration 140. 
a b o d 
Illustration 140. 
Diagram of the osteosynthesis of an old 
fracture of the femur with marked angu- 
lation 
a) before the operation 
b) after the cutting, the fragments are placed 
on each other with angulation 
0) the fracture is reduced by powerful bending 
to a straight position in direction of the 
three arrows, so that 
d) the nail can finally be driven in. An assistant now forces this point medially until the 
bones at the osteotomy site are straight, as indicated by 
arrows in illustration 140b, In this process, the bone 
must often be pressed surprisingly deep into the muscula- 
ture. When the angulation is corrected and the fragments 
are in a straight line, the nail is quickly driven in. The 
straightening is facilitated by a strong pull exerted by 
the extension apparatus of the table, which is connected 
with the foot by a set of pulleys. It is absolutely neces- 
sary to pay attention to the fact that it is possible to 
drive the nail in only if the angulation is completely cor- 
rected. One more technical maneuver must be observed in 
those proximally located osteotomies which are at about 
the level of the trochanter major, e.g, in the case of sub- 
trochanteric osteotomies. There exists, owing to the width 
of the marrow cavity, the hazard that the tip of the rod in- 
serted in the described way, may penetrate too far medially 
and may even endanger the hip-joint. For this reason, one 
must either press the lower end of the rod as far as possible 
to the medial side, as illustration 141 shows, or the rod 
must be inserted in the trochanter tip from the proximal end 
with considerable adduction 
of the proximal fragment as 
in the case of simple frac- 
tures (see chapter V). This 
procedure is recommended also 
in those cases where the osteo- 
tomy site cannot be exposed to 
such a degree that the rod can 
be easily inserted, e.g, in 
the case of a gunshot fracture. 
Then the appearance of the rod 
in the osteotomy wound is 
checked by direct vision, in 
cases of gunshot fractures it 
is palpated with the finger or 
even perhaps made sure in the 
X-ray, During subtrochanteric 
osteotomies, one usually in- 
cludes the trochanter tip in 
the operative wound anyhow, 
which facilitates the procedure 
considerably. If one does not 
proceed in this way, it is of- 
ten suitable not to cut the bone 
completely during the osteoto- 
my but only to such an extent 
as necessary to control the 
correct location of the rod. 
It is recommended to drive the 
nail in the proximal fragment 
at once, so that one can con- 
trol its position, since the 
musculature has the pronounced 
tendency to abduct this fragment 
violently, and this complicates 
the operation considerably. 
Illustration 1/»1. 
Insertion of the guide rod 
during the subtrochanteric 
osteotomy; 
a) wrong insertion. The tip 
gets too far medially. 
This is avoided by: 
b) correct insertion with 
powerful pressing of the 
handle of the rod in the 
direction of the arrow. 
Insertion o 277 
With the remaining bones, the technique of marrow 
nailing is the same as described in the preceding chapter 
in case^of simple fractures, so the lower leg nail is 
driven in from the tuberositas tibiae to the point where 
it protrudes out of the exposed marrow cavity of the 
proximal fragment, and then, its point is inserted into 
the marrow cavity of the distal fragment. The upper arm- 
and the ulna are nailed from the proximal or distal side, 
the radius from the distal side. 
As regards the osteosynthesis of the clavicle, a thick 
Kirschner-wire is usually sufficient as a marrow nail. Start- 
ing from the wound, it is first inserted into the distal mar- 
row cavity with an electric drill and drilled in so deeply 
that it pierces the skin and protrudes far from it. Then the 
wire is obliquely cut off the drill with the forceps. So 
this end acts as drill-point. The drilling machine is now 
attached to the wire end protruding from the skin. The wire 
is now drawn back to the point where its end can be easily 
inserted into the proximal marrow cavity, then* it is drilled 
forwards towards the sternal end. Then, the skin at the 
shoulder is incised at the place where the wire protrudes 
from the bone, the wire is bent and fastened to the bone ac- 
cording to RAUCHEMJALD*s technique (see chapter V) • The 
described procedure is demonstrated schematically in il- 
lustration 142. 
Illustration 11+2, 
Scheme of marrow nailing osteosynthesis of 
the clavicle. A thick Kirschner*wire is 
used as a marrow nail. 
a) Insertion in the distal fragment. 
b) Thereafter, the wire is obliquely cut, 
and the drill is attached to the other 
end. Then 
c) the wire is drilled into the proximal 
fragment towards its sternal end. 
One may also use wires with both ends sharpened, 
which makes the cutting unnecessary. 278 
Mistakes during the marrow nail osteosynthesis of 
the clavicle. 
The drill pierces the compacts and emerges from it 
with its point. It may possibly injure vessels and nerves ’ 
when it does not run precisely in the direction of the mar- 
row cavity* At all events, the marrow nailing must be per- 
formed with the utmost care. Because of the S-shaped bend 
of the bone, the point of the drill often does not arrive 
at the sternal end, but comes out the front of the bone be- 
fore, which is observed at once, since the bone is visible 
in its whole length under the skin. This is no serious 
danger, then the bone is exposed at that place and the 
nail bent round according to RAUCHSKWALD. Besides, one 
can also according to the author, simply turn the ends 
back sharply where they protrude from the skin at both 
sides, cut them short and make the cut ends disappear un- 
der the skin through the incisions by drawing back the skin 
with a pair of tweezers. This procedure has yielded ex- 
cellent results during a temporary osteotomy of the clavicle 
because of an aneurysm of the arteria subclavia. In this 
case, the clavicle was cut obliquely and rejoined not by 
wire suture as usual, but by marrow nailing as described 
above. The synthesis was so exact that it was not recog- 
nizable in the X-ray made immediately after the operation 
(see illustration 143). 
Illustration 143* 
Marrow nailing or the clavicle after its 
temporary resection because of an aneu- 
rysm of the subclavia. X-ray taken im- 
mediately after the operation. The osteo- 
synthesis is so exact, that the osteotomy 
cleft is not recognizable. 
The marrow nailing of the phalanges and metacarpal 
bones is performed in a similar way. We mention some ex- 
amples: AS a consequence of a shell splinter^injury of 
the wrist, which healed in an unfavorable position in the 
34 year old A. S. 2 years previously. An excessively ex- 
tended position of the metacarpo-phalangeal joints 2-5 
and loss of the thumb, so he could not bend his fingers 
nor form a fist. He practically could not use his hand. 
The metacarpals were obliquely osteotomized with a chisel, and marrow nailing was performed by means of Kirschner-wires 
in the-way described with the clavicle. The wires were bent 
back. The X-ray showed that the places of osteotomy were 
located not, as intended, in the middle of the bones, but 
Illustration 144« 
Marrow nail osteotomy of the finger meta- 
carpals 2-5 of the 34 year old patient A.S. 
because of excessively extended position of 
the fingers in the metacarpo-phalangeal joints 
after 2 year old shell splinter injury. 
a) before the operation 
b) after oblique osteotomy and marrow nailing 
c) after removal of the nails, 6 weeks later. 280 
far to the distal end. The mistake was caused by the fact 
that orientation was very difficult in the much deformed 
hand covered with scars. All the same, an excellent result 
was obtained9 The fingers retained the position they were 
expected to retain after the marrow nailing. A fist could 
be formed now, and the fingers could be stretched almost 
straight. The healing course was without complications. 
The nails were removed 6 weeks later (see illustration 144)* 
It is intended to replace the lost thumb. Marrow nailing 
has proved effective here also. 
Replacing of fingers. 
According to KljUMSCKMIDT*s method, who made splinters 
of the tibia heal under the abdominal skin, the author im- 
planted two 6-8 cm. long pieces of the fibula in the ab- 
dominal skin. A 3 cm. long incision of the abdominal skin 
was made, and then a canal was made with a straight bullet 
forceps. In this canal, the carefully resected piece of 
the tibia with periosteum was inserted and the wound closed. 
According to the authorTs experience, such a defect of the 
tibia causes no functional disturbance whatsoever. 
The fibula requires 3 months to heal in. Then, the 
fibula together with the skin is lifted and two incisions 
of the skin are made parallel to it, so that this segment 
of the skin can be made into a tube without tension sur- 
rounding the bone. 8 days later, the skin bridge on the 
lateral side is half-incised, 8 more days later, the skin- 
tube is wholly separated and the bone, together with the 
skin-tube is nailed on the wrist. 3 more weeks later, the 
skin-bridge at the fracture is again at first half and 
after 8 more days completely removed. Of course, these 
fingers cannot be moved, but they are very useful if all 
other fingers except the thumb or vice versa are missing, 
so that the hand is a prehensile organ again. This method 
of transplantation of bone splinters according to KLEIN- 
SCHMIDTfs principle appears to be the only possibility of 
transplanting bones, considering the hazard of infection 
with the wounds of this war (see also the following para- 
graph ). 
In case of juvenile patients, it may also be possible 
to follow NIKOLADONIfs example and to nail toes as substi- 
tutes for thumbs, thus preserving movable joints. This had 
not been possible previously because of the required long 
fixation in a plaster cast. 
In one such case, the 2nd - 5th fingers of the left 
hand had been lost by a shell splinter injury. In addition 
the patient had serious injuries of both elbows, forearms 
and upper arms with fistulae persisting for several years. 
The patient was 36 years old, the injury was l| years old. 
The thumb was quite movable, the elbwo-joint firmly fixed 
by bone and markedly fistulous. A removaT of sequestra 
from the trochlea humeri with broad flattening of the joint was made. Despite the suppuration the resection of the 
radius head was performed (see chapter VII) which yielded 
an excellent result with almost complete pronation and 
supination of the hand. A finger was now implanted by 
marrow nailing in the prescribed way, and the hand, use- 
less before, became again a good prehensile organ. 
The marrow cavity of the thumb is wider, so one re- 
quires fairly strong nails. As an example, we mention the 
$4 year old patient W.W. Two years ago, he sustained a 
serious injury of the right hand by a shell splinter. The 
thumb was stiffened in the joint at the base towards the 
back of the hand, so that opposition was impossible. Thus, 
the hand could not be used. In the middle of the metacar- 
pal an oblique osteotomy was performed and a curved marrow 
nail driven in from the proximal side. This nail had been 
prepared from a 4 mm thick V2A steel wire. Its end was 
bent before it was driven in. The hole at the base joint, 
into which the nail was driven, was prepared with an awl. 
(See illustration 145)* 
The thumb healed in 
good opposition - position - 
without any complications, 
Flexion and extension was 
retained in the joints of 
the thumb, so the patient 
was again able to write with 
his right hand. 
C. Indications for mar- 
row nail osteotomy. 
Generally speaking, the 
indications for marrow nail 
osteotomy are; 
1, a poorly fixed fracture, 
2. a fracture healed in an 
unfavorable position, 
3, a fracture healing with 
delay or not at all 
(pseudarthrosis) , 
4. a deformation of the bone, 
5* tumors of the bone. 
1. Marrow nailing of a 
poorly fixed fracture. 
If, according to the 
author Ts procedure, every frac- 
ture suitable for it is treated 
with marrow nails, this indi- 
cation does not occur from the first in most cases, but, as 
described in chapter VIA, pseudarthroses do occur even after 
marrow nailings when no "stable osteosynthesis" was obtained. 
Illustration 145* 
Condition after marrow nail- 
ing of a thumb stiffened in 
extreme dorsal flexion subse- 
quent to a 2 year old war in- 
jury of the 54 year old pa- 
tient W. W. It happens, however, comparatively often in the plaster 
cast or traction method that either the fracture cannot 
be fixed in a favorable position, or as is the case much 
more frequently, that the initial favorable position is 
lost in the course of the treatment, but this is usually 
noticed too late. The interposition of muscles which may 
make reduction impossible, is much more rare than general- 
ly assumed. No other impediments to reduction exist. There 
are a series of fractures with which poor results have been 
obtained by conservative treatment, as shown by experience. 
Some surgeons include the oblique fractures of the tibia in 
this group. The tendency of the surgeons for the operative 
intervention, however, is different in the various countries, 
On the other hand, there is greater agreement as regards the 
time when such a fracture should be operated. The unjority 
of the surgeons consider the middle of the second week the 
most favorable time. BLOCK mentions here the names of 
CIMINATA, DAHL-IVERSEN, DEMAL, GOETZE, KEPPLER (BIER), 
KIRSCHNER, KOENIG, LAMNOTTE, MATT I, MAGNUS, SPEED, WIDEN- 
HORN. At that time, the mechanical inflammation with its 
marked acidification in the surrounding area subsides due 
to decomposition of cells. The necroses are largely ab- 
sorbed. The operation causes a new mechanical inflammation 
with a new increase of hydrogen ions, as R.A. SCHMIDT was 
able to prove. If the chemical conditions of the wound 
are disturbed like that, an infection doubtlessly can de- 
easily, since the germs find favorable conditions 
in acid environments. Also the unfavorable increase of a 
local infection, e.g, in case of a furuncle, is principal- 
ly caused-by a shifting of the equilibrium of the ions, and, 
above all, by the rapid increase of concentration of the 
hydrogen ions against which the mechanisms of regulation of 
the body fail. Under the microscope, a delay of callus 
formation and chiefly an increase of decomposition can be 
proven. According to KOENIG’S X-ray studies, foreign sub- 
stances increase the decomposition of the bones and delay 
the healing, if they are effective at the time of its most 
intense regeneration. The decomposition is followed, it is 
true, by an intensified formation of callus. 
On the other hand, there are surgeons who consider an- 
other time of operation more favorable. Thus, REPIN, whose 
experience is considerable, operates in the first few days, 
as long as the muscular inactivity still exists, so he has 
the advantages of easier reduction. LEXER operates, if 
possible, only after 4 weeks, when the hyperemia in the area 
around the fracture is most pronounced. 
When such a fracture is presented for marrow nailing 
because of unsatisfactory position, one should lose no 
time and nail it at once, if the method is suitable at all 
for the case. Of course, the principles for the nailing 
of simple fractures apply to osteotomies as well. At all 
events, it should be first tried to nail the fracture with- 
out operative exposure. In a vast number of cases where 
the fracture may be reduced but not be retained in a favor- 
able position in a plaster cast or by the traction method, 
this is successful and will spare the patient the osteotomy. But even in those cases where no reduction was possible 
with the usual means, one should always try once more to 
obtain a closed marrow nailing. As experience has shown, 
this is almost always possible since marrow nailing has 
necessarily developed methods of more effective reduction 
(see chapter V), For this reason, the operation should 
be performed as early as possible because reduction is 
easier and motion of the extremity and thus normal circu- 
lation is restored earlier. 
If reduction fails, one will at once perform an o- 
perativo reduction with the patient in the same position. 
For this reason, everything must from the first be pre- 
pared for this circumstance, lest the operation is use- 
lessly prolonged, ‘lest narcosis need be prolonged, etc. 
Only a very small incision need be made usually, and then 
it is often surprisingly easy to place the fracture ends 
on each other by means of bone hooks. The maneuver of in- 
serting a raspatory between the fracture ends and of re- 
ducing the fracture by its lever-effect, has been often 
successful. Then, a guide rod and subsequently the nail 
is driven.in the distal fragment, a rubber drain is in- 
serted, and the skin is closed by sutures. Muscle sutures 
are usually unnecessary. One will, at most, close the fas- 
cia by a few sutures. Buried sutures are to be avoided, 
if possible. One should not make up onoTs mind too late, 
concerning this operative reduction, lost one loses too 
much time. By efforts at reduction protracted through 
hours, the patientTs life is greatly endangered by the 
shock-effect, as BOEHLER rightly emphasizes again and a- 
gain. 
If the fracture is older, callus masses of connective 
tissue and bone have already been formed which render a 
reduction without operative opening impossible. It may al- 
so be prevented by a shortening of the muscles. In these 
cases, it is useless from the first to lose time by reduc- 
tion maneuvers. One only injures the patient and the tissue 
if one is then forced to open the fracture after all. On 
the other hand, a brief trial does sometimes pay. It is 
surprising that it is possible to obtain a relatively easy 
reduction in some oases where oven little clouds of callus 
are observed. The roentgenograms of those marrow nailings 
look as if the nailing had been done weeks before. 
It is unnecessary to mention examples for the marrow 
nailing of poorly fixed fractures. All the fractures- in 
juvenils illustrated in this monograph arc such cases, 
since marrow nailing with children was made only if no sa- 
tisfactory position could be obtained with conservative 
treatment (see chapter V)• 
2. The marrow nailing of fractures healed in an un- 
favorable position. 
Hero the question of what is to be understood by an 
unfavorable position is much more urgent than in the case 
of a poorly fixed fracture, for firstly it is never possible 284 
to perform the nailing without opening the fracture, and 
secondly the operation is at the same time always much 
more serious, because the bone must be cut. For this 
reason, the responsibility for such a decision is much 
greater. One must agree with BOEHLER who asserts, that 
the indications for operative fracture treatment are made 
too frequently. A lateral shift for the width of the shaft 
is of no importance, if the axes of the fragments run in 
the same direction. In the upper arm, an angulation of 
30° involves no functional failure, but in the femur even 
an angulation of 10° impairs the function of the joint, 
according to BOEHLER. Only a functional indication can 
justify the risk of an operative reduction and in this 
sense we may define an unfavorable position of a fracture 
as one that causes a constant considerable functional dis- 
turbance, ao that a shortening amounting to more than 3 cm. 
causes a considerable disturbance of gait, a marked angu- 
lation of the upper arm considerably reduces the ability 
of using the arm. Of course this also depends on the oc- 
cupation and profession of the patient. In the individual 
case, the operation depends wholly on the kind of the dis- 
location. 
a. Procedure in case of dislooatio ad axin. 
In the upper extremity, only very marked angulations 
involve a functional failure. We mention, as an example, 
the case of the 26 year old patient R. p. He had a 1 year 
old shell splinter injury of the left radius and of the left 
ulna, just below the elbow joint, which had healed almost in 
a right angle position and impaired the use of the arm con- 
siderably, The bones were comminuted; pronation and supina- 
tion were impossible. A 5 cm, long incision of the skin was 
made where the ulna was curved most, and almost a 3 cm, long 
piece of the ulna was resected at that place with oblique 
sawed surfaces by means of a bow-saw as described above. 
Then, a marrow nail was driven in from the olecranon* 
Three months later, the marrow' nail was removed, and 
9 months later, the radius head was resected. A pronation 
and'supination mobility of the hand, restricted by about 
30°, complete flexion of the hand, and complete flexion and 
extension in the elbow joint wore obtained, so that P. can 
carry on his trade as a tailor again. 
In the lower extremity, even slight digressions from 
the straight axis involve considerable disturbances. Also 
in those oases, the angulation facilitates work with the 
bow-saw, since the leg usually heals in a bandy-leg posi- 
tion. For this reason, the angulation points outwards and 
presses the musculature apart. Thus, practically no muscles 
need be separated when the incision of the skin is made 
during femur marrow nailings. As an example, we mention 
the 34 year old patient L. W. Ho had a 2 year old traumatic 
bandy leg caused by a gunshot fracture of the left thigh. 
The wounds drained considerable pus for a year and finally 
healed. There w'as a marked axis-angulation of the femur 
in the middle with a shortening of about 7 cm. (see illustra- 
tion 146) . 285 
Illustration 146. 
a) Traumatic bandy leg caused by 2 year old 
gunshot fracture of the 34 year old pa- 
tient L.W# Shortening of 7 cm. 
b) after marrow nail osteotomy 
c) after removal of the nail, 18 weeks later; 
the shortening is completely corrected. A 6 cm. long incision of the skin was made over the 
place of the sharpest angulation. The bone was sawed at 
its outside and then broken. There was some splintering 
in the longitudinal direction. Marrow nailing was made 
in the described way. A violent suppuration lasting 2 
months occurred, with temperatures up to 40°. No plaster 
oast was required. Six weeks later, a tube abscess at the 
back surface of the femur was incised. The patient could 
get out of bed only after 11 weeks. The femur healed in a 
straight position with good callus, the fistulae closed. 
The nail was removed after 18 weeks (see illustration :146). 
The patient H.B. was a similar case. A marked angu- 
lation of the femur had existed for 8 months after a gun- 
shot fracture. It was a transverse fracture, which had 
healed in pure dislocatio ad axin. These transverse frac- 
tures are quite favorable for osteotomy. There existed a 
seeming shortening of 13 cm. The marrow nail was inserted 
from a small incision of the skin at the outside (see il- 
lustration 147) • 
a b 
Illustration 147. 
One year old gunshot fracture of the patient 
H. B. healed with marked angulation. Seeming 
shortening of 13 cm. 
a) before marrow nail osteotomy, 
b) after marrow nail osteotomy. 
The shortening was not only completely corrected, but 
the leg was even 1 cm. longer, since the callus had not 
been removed. The patient H. W. had a 4 year old traumatic bandy leg, caused by a simple fracture after an accident 
with a motorcycle. The seeming shortening amounted to 
cm. The bone was completely developed and was extremely 
hard. A wedge was cut out of the tibia, thus a trans- 
verse fracture plane was formed. The wedge had been ex- 
actly calculated previously. Also the fibula was resected. 
It took rather a long time - 4 months - until sufficient 
callus had developed. This delayed healing may be explained 
by the marked eburnization of the bone, partly also by the 
transverse plane of osteotomy. The final result, however, 
was excellent. The shortening was corrected, the leg was 
absolutely straight, the joints were freely movable (see 
illustration 148). 
Illustration 148. 
4 year old traumatic bandy 
leg caused by motorcycle ac- 
cident of the patient H.W. 
Marrow nail osteotomy after 
wedge-resection 
a) before the operation 
b) immediately after the 
operation 
c) after extraction of the 
nail, 4 months later. This wedge-resection has three disadvantages: 
The wedge must be exactly calculated and also ex- 
actly sawed out, so that the fragments fit after the osteo- 
synthesis; A transverse fracture plane is formed. Mathe- 
matically, this is the smallest possible plane of contact 
of the fragments. The oblique sections produce larger 
planes of contact and thus better healing prospects. If 
the nail is not absolutely firm, the transverse plane 
cannot prevent a rotation of the fragments. For this rea- 
son, the author has also operated such pronounced angula- 
tions according to HELFERICH*s principle of the oblique 
osteotomy. The bone is obliquely cut with a saw at the 
level of the most marked angulation. The inclination of 
the sawed surfaces is of little importance. At all events, 
it need not be as exactly calculated as the wedge during 
the wedge-resection. With short sharp angulation an 
angle of about 45°, with long flat angulation a somewhat 
more sharp angle to the longitudinal axis is recommended. 
One must, however, see to it that the axis of the sawed 
surface with the angulated plane passes exactly through 
the vertex of the angulation and precisely cuts the angle 
of angulation in half. Otherwise, the section surfaces do 
not quite fit; for if a straight marrow nail is used, the 
bone must be completely straight eventually, no matter how 
it is cut (see illustration 149)• 
Illustration 149« 
Oblique osteotomy according to HELFERICH in 
case of bones with marked angulation. 
As shown by the illustration, no bone is wasted as 
in the case of wedge-osteotomy. Two bone prominences occur 
but they have no disturbing effect. 
We mention an example for such a marrow nail osteotomy 
of the femur. It is a 3 year old closed fracture of the 
femur after an accident to the patient E. 0, (see illustra- 
tion 150) • Illustration 150* 
Example of a marrow nail osteotomy with use 
of HEU’ERICH's principle. Three year old 
fracture of the femur of the patient E. 0. 
The callus formed considerably faster and 
more intensely than in the preceding case. 
b. Correction of the dislooatio ad peripheriam. 
This dislocation is comparatively rare. It occurs as 
a mistake even after marrow nailing, if, during the osteo- 
synthesis, the correct rotation-position of the distal frag- 
ment was disregarded, or if the synthesis was not stable 
enough in case of a transverse fracture. 
In the upper extremity, the author recommends the step- 
like shortening. The bone is transversely cut with a saw 
at any place one chooses, then a longitudinal section about 
2 cm. long passing through the central axis is made on the 
one fracture end. Thereafter, the bones are rejoined and 
the arm is brought in its proper rotation position. The 
prolongation of the longitudinal sawed section to the other 
fragment is marked with a knife by incisions into the peri- 
osteum of the other fragment. The end of this fragment is 
then caused to protrude from the wound by bending the ex- 
tremity, as has been described before, and a longitudinal 
sawed section is also made there. The periosteum with 
the possibly adherent soft parts is now scraped off on the 
one fragment on one side, on the other fragment on the 
opposite side. These exposed halves are then cut off by 
corresponding transverse sawed sections. A simple trans- 290 
verso cutting and marrow nailing is usually not certain 
enough, since the shortened musculature acts powerfully 
to restore the former dislocation (see illustration 151). 
As in -case of every 
shortening of the upper ex- 
tremity, an additional con- 
trivance is necessary to 
prevent a new elongation. 
It is described in particular 
in the section on pseudar- 
throses• 
With the lower extremity, 
this method must be used with 
great care, lest any greater 
shortening occurs. Only one 
step of only 1 cm. is suf- 
ficient. If the leg is con- 
siderably shortened, how- 
ever, any additional shorten- 
ing is a serious loss. If. 
necessary, an additional e- 
longation-osteotomy should 
be performed. Then, special 
nails are used. At some 
distance from the osteotomy- 
site, 2 lateral bolts are 
driven in through slits, as 
when Y-shaped nails are 
used (see illustration 152). 
Illustration 151. 
Diagram of the rotation- 
osteotomy by step-like 
shortening according to 
KUENTSCHDR• 
c. Correction of the 
dislocatio ad latus. 
This dislocation alone 
is rarely an Indication for 
osteotomy, since a lateral 
dislocation even as much as 
the width of the shaft in- 
volves no functional failure 
whatsoever, if it is not com- 
bined with another disloca- 
tion, But greater lateral 
dislocations are rare, be- 
cause in this case a very 
long callus-bridge is neces- 
sary. These oases usually 
become pseudarthroses.' As 
there is no shortening, os- 
teotomy presents no tech- 
nical difficulties here. 
Illustration 152, 
Rotation-osteotomy with mar- 
row nailing according to 
KURNTSCHER. There are only 
a few cases in which large steps 
are made in the lower extremity 
viz. in which marked shorten- 
ings do not matter. This ap- 
plies if the other leg is mis- 
sing or shorter. d. Correction of the dislocatio ad longitudinem cum 
stractlone * 
With the long tube bones, this dislocation is rare 
too, but statistics contain numerous cases where fractures 
of the femur healed with elongations up to 7 cm. and even 
more because, of excessive pulling during the traction 
treatment. These cases can be effectively treated with a 
shortening osteotomy by means of marrow nails as described 
in the following paragraph. 
e. Correction of the dislocatio ad longitudinem cum 
contractione. 
This dislocation is always associated with a dis- 
locatio ad latus, but also with other dislocations, for 
all these cases usually are combinations of various dis- 
locations. The operative procedure of marrow nailing de- 
pends on the most evident dislocation. With a shortening 
without angulation, the osteotomy is frequently very simple. 
The cleft between the two fragments is usually clearly 
visible or palpable through the muscles. Then a broad 
chisel is pushed through the musculature, which runs in 
the same direction as the cleft. Thereafter, the chisel 
is driven through the bone bridge with powerful blows. 
The bone bridge is now completely severed by twisting the 
chisel and powerful bending. The separation is usually 
made rather smoothly along the corticalis of the one or the 
other fragment. Then, the fracture ends are brought more 
to the surface by further bending, and the marrow cavity 
is drilled open. The reduction is performed in the manner 
described at the beginning of this chapter, by V-shaped 
arrangement and subsequent pressing the fragments into 
a straight position. As an example of an almost pure 
shortening dislocation, we mention the 21 year old patient 
G. D.> He had a 2 year old shortening of the lower leg a- 
mounting to 4 cm. caused by an accident. The fracture was 
located the width of a hand above the ankle joint. A longi- 
tudinal incision was made at the front edge of the lower 
leg. Marrow nailing osteotomy was performed in the des- 
cribed way, and the shortening was completely corrected. 
(See illustration 153)* 
The lengthening of the lower leg caused a pes equinus, 
which was corrected by tenotomy of the Achilles tendon ac- 
cording to VULPIUS. 
As an example of the correction of a combined disloca- 
tion, we mention the patient E. F. As sequelae of a 2 year 
old gunshot-fracture of the femur, there existed a shorten- 
ing, lateral dislocation and angulation, in the nature of 
a bandy leg. The result of the marrow nail osteotomy was 
a complete correction of the shortening without any angu- 
lation (see illustration 154). 
Further examples of marrow nailing for correction of 
dislocations are mentioned in the following chapter VII 
under the heading "osteotomy of infected fractures”. 292 
a be 
Illustration 153* 
a) 2 year old fracture of the lower leg of 
the patient G.D., healed with 4 cm. 
shortening, 
b) complete correction of the shortening 
by marrow nail osteotomy, 
c) after removal of the nails. 
Illustration 154* 
26 year old patient E.F* 
Example of the correction 
by marrow nail osteotomy 
of a 2 year old gunshot 
fracture of the femur, 
which had healed with 
shortening, angulation 
and lateral dislocation. f. Lengthening by means of marrow nailing. 
Only those cases are now left for discussion where 
there was originally a marked comminution of the fracture 
site and where the fragments healed together in a con- 
glomeration with shortening. In these cases, the dis- 
location can bo corrected only by a lengthening-osteotomy. 
The same often applies to oblique fractures with very 
steep fracture lines, which have healed with marked 
shortening. 
It happens comparatively often that a bone is shorter 
than that of the other side. This may result from various 
causes: Either it has been too short since birth, or it 
has been shortened by a fracture or by an operation because 
of a tumor, or its growth has been impaired by a disease 
or even X-ray treatment of the epiphyseal line in child- 
hood (A. BECK), or the corresponding bone of the other 
side has grown excessively by chronic inflammatory stimu- 
lation, etc. The numbers of these cases are certainly 
large, and it is frequently desirable to have the bone 
lengthened. Firstly," for cosmetic reasons, secondly there 
is an additional functional indication, though this is 
important only with the lower extremity. In the upper ex- 
tremities, even considerable shortenings produce no marked 
functional disturbance, while even a few cm. shortening 
of the lower extremity does, as is well known. In spite of 
that, the operative lengthening has been an extremely rare 
operation previously (apart from the described false 
shortenings where there is dislocation, caused by a frac- 
ture of the femur healed in a bandy-leg or knock-knee po- 
sition and this is corrected) . This has been caused by the 
extraordinary difficulty of the operation, the often un- 
certain results and the long duration of the treatment. 
This operation is also often impossible because the bone 
tissue no longer has the power of regeneration necessary 
to fill the gap caused by the lengthening with new callus, 
or the soft parts, the connective tissue, the musculature, 
vessels, and nerves do not permit a greater lengthening. 
All this explains why lengthenings are made so rarely and 
why indications for functional reasons are made only in a 
few chosen cases, i.e. only the lower extremity is lengthened. 
In these cases the indication is all the more justified since 
dissimilar legs and dissimilar use of them inevitably cause 
early detrition of the joints, atrophies, arthroses, not on- 
ly of the lower extremity but also of the pelvis and chief- 
ly of the vertebral column. 
For this reason, the attempts of solving the problem 
of lengthening, have been numerous. KIRSCHNER was the 
first to obtain satisfactory results through his idea of 
performing the lengthening in the sound Cone, which still 
possesses unimpaired power of regeneration. KIRSCHNER cut 
the bone and applied powerful traction for a long time. The 
ordinary extension wires turned out to be too weak, so thick 
Steinmann-wires were used. In 1922, BIER demonstrated suc- 
cessful lengthening - operations on dwarfs. He out the peri- 
osteum, corticalis, and marrow in one plane, but the bones 
were not drawn apart immediately, but were left standing be- 
side one another so that the "metaplastic stimulation” pro- 
duced by the bone fracture could have its full effect on the surrounding tissue. Maybe this really was only the effect 
of the outflowing marrow (see chapter III). Then, traction- 
wires were inserted through the crests of the pelvis and 
through the condyles of the femur, and a long and intense 
traction was applied. Thus, the extension-weight of a 16 
year old girl-dwarf, whose body weight was 30 kg, amounted 
to 20 kg per leg. The defect was admirably filled with 
bone tissue; the lengthening amounted to 4,5 cm. = 1/6 of 
the original length of the femur. 
I. SCHULTZ, Riga, gave an excellent demonstration of 
this extension method. He gradually increased the extension 
so that a maximal weight of 20 kg and more is arrived at 
within 7-10 days. The periosteum in connection with the 
soft parts is gradually extended and, if the traction is in- 
creased slowly, even the osteogenic areas are hardly damaged. 
The powerful extension had to be retained for a long time. 
In no case could the leg be used earlier than after 5 months. 
Because of the hazard of a possible pseudarthrosis, the exer- 
cises of motion must be done with extreme caution. Due to 
these hazards and disadvantages, this lengthening operation 
has not been popular and is rarely performed. 
There are much better chances with the marrow naill 
The disadvantages of an excessively long bed-rest and of 
such an enormous traction do not apply. The marrow nail 
is strong enough to resist the great forces which arise 
and to guarantee full ability of using the limb after a 
few weeks. Also with marrow nailing it takes many months 
to fill the large defect with new bone, but the patient 
need not stay in bed, but can be discharged from the hos- 
pital and carry on his trade. 
Also in case of the extension-method, operative leng- 
thenings are performed only on the femur, since it has con- 
siderably greater power of regeneration than the lower leg. 
With marrow nailing, there is an additional reason; a "stable 
osteosynthesis" may be obtained much easier with the femur 
than with the lower leg. 
The author has mentioned two methods: In the one case, 
the fragments are kept apart by living bone, in the other 
case by dead bone. When selecting the place to cut the 
bone, one should prefer the middle of the bone for marrow 
nailing, because then the nail is held firmest in the two 
fragments, if this is not the place of the old fracture as 
well. Then it is suitable to saw the bone farther to the 
proximal side, in order to observe here also KIRSCHNER's 
principle of performing the lengthening-osteotomy on the 
sound bone. The question of whether the bone should bo cut 
transversely or in a step-like manner, has been answered by 
KIRSGENER in his lengthenings, in favor of transverse cut- 
ting, since the periosteum is better conserved then. For 
the same reason, the author thinks, according to his ex- 
perience, the transverse or slightly oblique cutting more 
favorable in case of lengthening by means of marrow nail- 
ing. 
We demonstrate these methods by two examples; The 22 year old patient W.A. had a 4 month old gun- 
shot fracture of the right femur. It was a long oblique 
fracture, which had healed in extension with 7 cm. short- 
ening and good formation of callus. The fracture occupied 
the whole middle of the bone. There was no angulation. The 
bone was transversely cut with a saw proximal to the old 
fracture. Then intense traction was applied for about 15 
minutes. During this period, a 5s cm. long piece of the 
fibula of the same leg was resected together with the peri- 
osteum. After the gradual extension of the musculature, it 
was possible to insert the piece of the fibula in the bone 
defect which had been formed. A 2 mm thick Kirschner wire 
was introduced beside the guide rod through the marrow cav- 
ities of the proximal fragment of the fibula and of the 
distal fragment, and the end protruding from the trochanter- 
tip was bent down. Thereafter, the marrow nail was driven 
in as usual. The Kirschner wire holds the fibula piece ex- 
traordinarily firm, since it is only under stress in case 
of shearing off. It is impossible to remove the piece with 
the hand. Eight days later, the patient moved his leg 
without pain and used it a-fortnight later, but then he 
felt pains in the hip-joint, the cause of which could not 
be determined. For this reason, he had to rest in bed for 
4 weeks, afterwards he could use his leg again. No dis- 
location occurred, though callus was formed only slowly 
(see illustration 155)• 
Illustration 155» 
Lengthening osteotomy on the 22 year old 
patient N. A* 
a) After insertion of a tibia splinter 
covered with periosteum, which is held 
extraordinarily firm by a Kirschner wire 
b) Three months later, the defect has only 
partly been filled with callus. In order to accelerate healing, a tibia splinter 
covered with periosteum was taken from the same side, and 
was pushed between the bluntly separated musculature and 
the osteotomy site. It was unnecessary to fix it special- 
ly; since the bone ends cannot move because of the marrow 
nail. It was sufficient to close the musculature above 
the splinter again by 2 catgut sutures. Two weeks after 
this intervention, the patient was able to walk around. 
The final success was excellent. The defect was completely 
filled with bone. The lengthening of 5 2 cm* fully per- 
sisted, There was no angulation (see illustration 156). 
a b 
Illustration 156* 
Lengthening 'osteotomy of illustration 155• 
a) After implantation of the tibia splinter 
covered with periosteum, 
b) the defect was completely filled with 
bone (X-ray taken 8 months after the 
operation for lengthening). 
One year ago, the 25 year old patient H.R. sustained 
a pistol shot injury of the right thigh which caused a 
comminuted fracture, which healed in the plaster cast with 
5 cm. shortening. There was a fistula. Four months after 
removal of the sequestrum and scraping out the fistula, a 
slightly oblique osteotomy was performed across the old 
fracture. After about 15 minutes of intense traction, a 
6 cm. long boiled bone piece was inserted in the defect. 
The insertion was difficult and could be effected only by 
separation with powerful prying between the fracture ends 
and the bone piece partially inserted in the defect. Then, 
the marrow nail was driven through all 3 marrow cavities, 
and a very firm union was thus obtained. After the oper- 
ation, the leg was 1 cm. longer than the other (see illus- 
tration 157) • a be 
Illustration 157* 
Marrow nail lengthening - osteotomy# 
One year old pistol shot fracture of 
the femur of the 25 year old patient 
H.R., healed with 5 cm. shortening. 
a) After slightly oblique cutting and 
insertion of a 6 cm. long boiled 
bone piece. 
b) 6 months later, the defect is filled 
up almost completely with callus. 
c) Complete filling up of the defect 
after 12 months. 
The course of healing was without complications, the 
patient got up from bed after a fortnight and could use 
his leg at once. The formation of-callus was slow even 
considering the size of the defect, but the patient was 
not hospitalized in that period and carried on his trade. 
Marrow nail lengthening can be performed in consider- 
ably more exact amounts than extension-treatment. Of 
course, differences of 1 - 1| cm. are of no importance. 
During all lengthenings, no damages to nerves and 
vessels have-been observed, though the extension was 
quit® abrupt after all. Also in case of the considerable 
shortenings which wore corrected in an equally sudden way 
by extension of a dislocation ad axin, no such disturbances 
occurred. An anesthesia in a region of the skin the size 
of a small hand above the patella * which had appeared in one 
case after lengthening for 5i cm., was not ■ considered the 
consequence of the lengthening, but the direct consequence 
of a contusion of nerves during the operation. It dis- 
appeared 8 months later. Such a marrow nail lengthening-osteotomy may also be 
performed'with gradual lengthening. Then the intervention 
must be made in two operations. First, the bone is cut 
transversely with the counter-incision-saw through two 
comparatively small wounds. Then, a poworvul wire-extension 
is applied for 7-10 days, as described in the discussion 
of extension treatment. On the 10th day, the outer wound is 
reopened and the marrow nail is inserted in one of the two 
ways. The disadvantage is tho twofold operation. The author 
proposes to avoid this by the use of a twofold nail, which 
permits extension and thus lengthening, though no shortening. 
For tho lengthening on persons with stunted growth, the last 
mentioned methods of gradual lengthening appear to be very 
useful, particularly since they cause only short interruptions 
of tho ability of carrying on one*s work, (cosmetic lengthen- 
ing) . 
HURZOG has demonstrated another method of marrow nail 
lengthening. To retain the distance of the bone ends, he 
does not insert bones, like the author, but obtains the same 
effect by metal bolts across tho nail. HERZOG'S experience 
is excellent. The hazard of infection is doubtlessly less 
groat in this procedure. This is a great advantage, for it 
is always a considerable risk to use a bone splinter, as 
mentioned before. Particularly after gunshot fracture, tho 
condition of the soft parts and of the bone is so seriously 
damaged that a lengthening-osteotomy is by no means indi- 
cated, especially if a serious infection or even gas-gan- 
grene existed. The power of regeneration is so seriously 
reduced that an attempt at operation is irresponsible. Even 
the musculature is pale and decayed in those cases and does 
not permit any considerably extension. For this reason, on- 
ly a shortening osteotomy of the sound leg may be considered. 
1). Shortening osteotomy by means of marrow nails. 
Also shortening osteotomies have been rather rarely per- 
forms d previously. This was caused by tho fact that the 
previous methods could not certainly guarantee the healing 
result, for, after a shortening, it is much more difficult 
to hold the bone ends in a favorable position in a plaster 
cast than a fresh fracture or a normal osteotomy, since* all 
the soft parts and particularly tho muscles become very 
slack. Thus, the protection, which the soft parts afford 
against a lateral dislocation, is almost completely missing, 
and tho plaster cast fails for the same reason. Marrow nail- 
ing made it first possible to remove these disadvantages and*" 
render shortening-osteotomy a simple and certain operation. 
Indications for operation are various and frequent. 
Marrow nail shortening of tho sound leg in case of fractures 
healed with shortening was proposed and demonstrated by ad- 
mirable examples by K. H. BAUER. These cases are particular- 
ly numerous after a war. If tho legs differ considerably in 
length, an adaptation by orthopedic shoes is always only an 
insufficient expedient. The danger of such differences in 
length for legs, pelvis and vertebral column has been men- tioned in the preceding section. BAUER proposed shortening 
even in case of vascular defects. BOEHLER performs marrow 
nail shortenings also in case of nerve defects caused by 
gunshots. He proposes this for defects of the ischiaticus 
as well, to make possible a suture of this nerve without 
tension. A log without the ischiaticus functioning is use- 
less, thus the shortening is absolutely justified. The 
sound log may be shortened if necessary also in this case. 
E. GUENZ has pr oposed Henlo f s operation by means of marrow 
nailing. In his time, HENLE proposed to shorten both bones- 
in case of an ischemic contraction of the forearm. However 
excellent this proposal may bo theoretically, the practical 
results were unsatisfactory since, in the forearm, it is 
particularly difficult to make the two bones heal in a 
favorable position. For this reason one has preferred to 
shorten the wrist bones, which certainly is no ideal so- 
lution. The marrow nail has overcome these difficulties. 
In case of pseudarthroses of one forearm bone, the 
author always shortens the other bone, ho also shortens as 
often as he can in case of pseudarthroses of the upper arm. 
Despite these various indications, the technique is 
absolutely uniform and typical. The bone is always cut in 
the middle, since there a stable marrow nail osteotomy is 
most certain. A transverse osteotomy is not indicated,, since 
it is frequently not rotation-proof if the marrow nail is not 
absolutely firm. By no moans, should it bo performed on the 
forearm, as was particularly pointed out by GUElxZ. At that 
place, the tendency to rotate at the osteotomy site is par- 
ticularly great. The step-like osteotomy has no special ad- 
vantages as contrasted to the oblique one, because the hazard 
of damaging the periosteum is greater with it. The author 
proceeds as follows: First, he arrives at the middle of the 
bone with a small incision. Then, the bone is obliquely cut 
with the described countcr-incision-saw, and the bone ends 
are pushed out of the wound by bonding the extremity at the 
osteotomy site. Then, the musculature together with the 
periosteum is pushed back at both ends as far as the intended 
shortening requires. The shortening is exactly checked with 
a boiled metal rule. Then, a corresponding piece is sawed 
off both bones in such a way that the new sawed surfaces of 
the bone ends are exactly parallel to the original sawed 
surface. Thereafter, the bones are rejoined by marrow nail- 
ing in the described way. If a femur is nailed, a guide rod 
is introduced into the proximal bone end from the wound, on 
the tip of which the nail is driven from the trochanter. The 
other bones are nailed without a rod. 
Wo now mention some examples for marrow nail shortening 
osteotomy: 
Two and a half years ago, the 25 y-ar old patient O.K. 
sustained a fracture of the left femur caused by a shell- 
splinter, which healed with 9 om. shortening. The leg was 
damaged by numerous scars, the knee and ankle joint wore stiff. 
There were many small shell splinters around the old fracture. 
For this reason, a lengthening of this leg did not 
appear indicated, and an oblique shortening of the sound 300 
leg by 7i cm. was made. The healing course was normal. 
The patient rose from bed 8 days later, but when he used 
his leg, he had the feeling that the leg was somewhat 
loose at the osteotomy site. Slight wabbling movements 
were possible, indeed. This was caused by the fact that, 
during this marked shortening, the whole middle part of 
the femur bone had to be removed and in that part the mar- 
row cavity is narrow. The movement of the nail-point caused 
a stimulation for callus-formation, within the marrow cav- 
ity, which is distinctly recognizable in the X-ray (see 
illustration 158). 
Illustration*158. 
Marrow nail shortening os- 
teotomy of the sound leg 
after an old gunshot frac- 
ture of the left femur of 
the 25 year old patient 
O.K. 
a) left femur 
b) right femur before 
shortening, 
c) after cm. shortening 
d) shortly after nailing 
e) marrow callus has formed 
around the point of the 
nail. , 301 
Even after 6 weeks, the looseness of the leg at 
the osteotomy site disappeared, but the patient still had 
no firm support on his leg. It turned out that there ex- 
isted, in addition, a loose knee which certainly had not 
existed before. Experience has shown that the knee became 
loose in the first few weeks after the operation in case 
of all such extensive shortenings of the femur. 8-9 weeks 
later, this symptom always disappeared without any special 
treatment. This happened also in this case. This symptom 
may be probably explained by the fact that always a certain 
muscular tonus is necessary for the normal fixation in the 
knee-joint. If this tonus is suddenly completely absent, 
as in case of such a marked shortening, the symptom of the 
loose knee occurs. The musculature is gradually shortened, 
and its normal tonus is testored, and thus, the loose knee 
disappears. This is in accordance with an observation of 
HOEMANN, who found the symptoms of a loose knee in case of 
a weakness of the muse, vastus. It could be corrected by an 
operative shortening of the muscle. 
Illustration 159• 
Oblique osteotomy with cm. shortening 
after healing. The same patient as re- 
presented in illustration 158. After the 
removal of the nail, at the end of a period 
of 12 months. 
After 8 weeks, the patient was completely without 
complaints. The leg had become absolutely firm without 
an angulation, the joints could be moved freely (see il- 
lustration 159) • The 22 year old patient W.S. is mentioned as an ex- 
ample of a stop-like shortening of the femur. Two years a- 
go, he sustained a gunshot fracture of the right femur 
with 5 cm, shcrtening. The right knee and the left hip- 
joint were completely stiff. The right femur was shortened 
by 5 cm* The left femur was shortened in a step-like 
manner by 4 cm. The patient, who had been unable to walk 
before t.he operation and had to stay in bed for 2 years, 
could use his leg again afterwards. He got up from bed 
4 weeks after the operation. The healing course was with- 
out complications. Also in this case, there existed the 
symptoms of a loose knee for some weeks. The marrow nail 
was removed after 6 months. The leg had become absolutely 
firm in the intended position (see illustration 160). 
Illustration l60. 
Step-like shortening osteotomy of the 
sound leg for 4 cm. of the 22 year old 
patient W.S. His right leg had been 
shortened for 5 cm. by a gunshot frac- 
ture of the femur. 
a) after the shortening 
b) five months later 
c) after removal of the nail 6 months 
later. 
As an example of a shortening of the upper arm be- 
cause of a 6 cm. long defect of the nervus radialis, we 
mention the 32 year old patient E.F., who had a 1 year 
old gunshot fracture of the right upper arm. The frac- 
ture had healed by firm bone with a lateral dislocation. 
The nervus radialis had a 6 cm. long defect at the mar- gin of the lower third of the upper arm. The old frac- 
ture was left intact, in order to not complicate the o- 
peration unnecessarily and not to cause unnecessary nec- 
roses. So a 7 cm. long piece out of the middle of the 
bone was resected with an oblique section-plane. In ad- 
dition, the bone ends were fixed to one another by a thick 
Kirschner wire, in order to prevent a separation of the 
fragments. The nail was driven in from the distal end at 
the beginning of the old fracture. Thus a straight 11 mm 
thick femur nail could be used (see illustration l6l). 
Illustration l6l. 
Shortening osteotomy of the upper arm with 
a 6 cm. long defect of the nervus radialis. 
There was a 1 year old gunshot fracture of 
the upper arm, healed with a lateral dis- 
location (32 year old patient E.F.) 
Condition after marrow nail osteotomy. 
The osteotomy healed by firm bone in the intended 
position. After k weeks the nerve was sutured, which 
was possible without any tension. Despite this, a later 
examination after 1~ years showed no success. Of course, 
it is quite possible to perform both operations, osteotomy 
and nerve suture simultaneously, but the principle of o- 
perating in two stages permits making exposure smaller and 
thus lessens the hazard of infection. 
If the sound leg is shortened, man as a whole be- 
comes shorter. Some people say that this might cause 
mental depression. Doubtlessly everybody endeavours to 
appear as tall as possible. For this reason, the wild 
tribes wear a high coiffure, the ladies wear high heals, 
kings a crown. We meet this tendency even among animals, 304 
and know that an animal is not impressed by the bulk of 
another animal, but only by its height. The antlers of 
the stag,too have a similar importance. On the other 
hand, the sign of humility and servility is the "self- 
diminution” the bow, lifting one's hat, etc. Thus, the 
idea that mental depression might develop, can be under- 
stood. The author, however, could not find the slightest 
clue for any such depression with his ”shortened,Tpatients, 
though some persons refused the proposed intervention. At 
any rate, one never will disturb these deep-rooted senti- 
ments without conclusive reason and will shorten the lower 
extremity only with exact indications. 
With the forearm, one may also consider a shortening 
in the form of the above mentioned Henle-operation. Its 
indication is the inability to use the arm or a consider- 
able reauction in the use of the hand and forearm as the 
consequence of an ischemic contraction. As a matter of 
fact, amazing success may be obtained by this method. As 
regards operative technique, one of the 5 methods des- 
cribed in the section on marrow nailing of pseudarthroses 
should be used. As examples, we mention two cases of E. 
G-TJENTZ. 
Fifteen year old school-boy. Ischemic contraction and 
paralysis of the ulnar nerve by a gunshot through the right 
shoulder with injury of the arteria subclavia and suture of 
it. Since because of the markedly increased sensitivity no 
reduction apparatus or bothersome bandages were tolerated, 
the forearm was shortened by 3 cm. During the nailing, the 
fragments were easily reduced. On 16 August 1943 operation, 
plaster cast for 8 days. Immediately free movability of 
pronation and supination of the hand. The claw-like position 
of the fingers decreased considerably. The active movements 
of the fingers improved a good deal. X-ray control on 11 
November showed complete bone healing, the nails were re- 
moved on 1 February 1944* 
• A 20 year old man had sustained, at the age of 1§ years, 
a supracondylar fracture of the humerus with consecutive 
ischemic contraction, which was in right-angle flexion posi- 
tion and excessive supination and could be used only for 
rough holding of some objects. Now the patient desired to 
be able to use his hand well while working on a card-index. 
Since the X-ray showed that the wrist bones were well de- 
veloped and no nerve defects existed, so that a possible 
function could be expected, a shortening osteotomy was per- 
formed. Three cm. resection during transverse osteotomy, 
which turned out to be unfavorable, because the bones kept 
their distance and the period from the beginning of Feb- 
ruary to November of the same year was necessary to pro- 
duce complete bone healing. The hand was brought in a 
slight pronation and could be extended up to the straight 
direction after removal of the plaster cast, which had 
been applied for 11 days. It was difficult to form a fist 
with opposition, since the flexor profundus was very weak. 
For this reason, a transplantation of the brachioradialis 
to the profundus-sinews of the 2nd and 3rd fingers was made . 
The patient is now quite able to work on his card-index and 
to use his fingers in this work. The nails were removed one 
year after the operation. k . Marrow nailing of fractures with delayed healing 
or no healing (pseudarthroses)V 
The best definition of the term "pseudarthrosis" was 
given by GULEKE and is based on the roentgenological obser- 
vation of the closing of both marrow cavities without any 
bony bridging over of the fracture cleft. This implies 
that the existing condition is final and no further develop- 
ment can be expected without special measures. Quite the 
opposite is the condition of the delayed healing of a frac* 
tune, where a bony bridging over is still possible* 
As has been described in chapter III, there are 2 causes 
of pseudarthroses: 
1. deficient regeneration of callus within the fracture 
cleft, and 
2. the wrong differentiation of this callus due to 
mechanical causes, so that no bony bridging over oc- 
curs. 
The second cause is by considerable the more frequent. 
Deficient fornation of callus may have either general 
or local causes. The general causes are: marasmus, dia- 
betes, scurvy, tuberculosis, lues, etc. Of course these 
causes will be treated casually, i.e. to try to control the 
original disease. As the author was able to show (chapter 
III) it is possible to stimulate intensely the formation of 
callus by nails of strong chemical effect. The clinical use 
of this principle, particularly by STOTZ - Giessen and MAATZ - 
Kiel, has been described before. 
The number of these pseudarthroses however, is very 
small indeed, as mentioned above, as contrasted to those 
mechanically caused. In these cases, the pseudarthrosis is 
not caused by no or insufficient formation of callus or by 
absence of bone formation. On the contrary, we have ob- 
served that sufficient callus is formed in most cases, but 
that there is a cleft through this callus. With this cause, 
marrow nailing appears to be the method of choice during 
causal treatment. The nail absorbs all injurious tensions 
and for the first time guarantees an undisturbed develop- 
ment to the callus, since there was no remedy before to e- 
liminate the injurious minute movements. Thus it is the best 
prophylactic against pseudarthroses as well. Thus, the au- 
thor has been informed of no case of a pseudarthrosis after 
successful marrow nailing. If pseudarthrosis did occur after 
marrow nailing, the cause was always an insufficient mechani- 
cal solidity of the nail. A marrow nailing of the forearm is 
mentioned as an example. A resection of the bone ends had 
been performed in some other hospital on a 23 year old pa- 
tient because of a pseudarthrosis after gunshot fracture of 
both bones. This resection, however, had been performed not 
obliquely but transversely so that the marrow nail was not 
rotation-proof. Thus, a pseudarthrosis occurred despite 
enormous formation of new bone (see illustration 162), 
curs. Generally speaking, such 
pseudarthroses after marrow 
nailing are quite rare indeed. 
Even slight jaggedness of a 
fresh transverse fracture is 
sufficient to clinch the frac- 
ture planes together and to 
make the marrow nailing ro- 
tation-proof, particularly 
since the muscle traction 
still presses the teeth on 
each other. This does not 
apply to exact resections, 
where 2 completely level 
planes are confronted, and 
the muscular traction on the 
forearm is no longer so ef- 
fective because of the re- 
moval of the bone fragments. 
The psoudarthrosis is a final 
conditions Any treatment with 
medicines, hormonoids, or hor- 
mones is useless. For this rea- 
son, one does not read of any 
convincing proof for a success- 
ful treatment in a critical ex- 
amination of the respective 
literature. 
During any treatment of 
pseudarthroses, the very first 
thing to do is to start the 
halted process of callus form- 
ation going again. Then one 
must see to it, that now the germination of the callus in the 
fracture cleft is mechanically protectecPand thus forms bone 
and not connective tissue (see chapter III). 
In case*of delayed healing of fractures, the latter a- 
lone will do, theoretically considered, viz. the insertion 
of a marrow nail. As an example, we refer again to the 
case in chapter III. This case was a fracture of the tibia, 
which showed no bone callus in the X-ray even after B weeks 
in a plaster-cast. Marrow nailing was possible without 
opening the fracture, though mth enlargement of the fracture 
cleft for ij cm. After the marrow nailing, the formation of 
bone was so intense, that the whole fracture cleft, lj cm. 
wide,w;as filled with bone. 
We mention the 36 year old patient E.P. as one more 
example of delayed healing of a bone fracture. He sustained 
a simple fracture of the left lower leg by a traffic-accident. 
The fracture had not become firm during 6 months of treatment 
in plaster. The fracture was absolutely freely movable. The 
X-ray showed no callus at all, only resorption was manifest 
at the bone ends. 'On the other hand, the marrow cavities 
were not yet closed by bone. For this reason, it was quite 
possible to insert a marrow nail as in case of a simple frac- 
ture (see illustration 163)- 
Illustration 162. 
Pseudarthrosis after marrow 
nailing, after resection of 
radius and ulna. The junc- 
tion was not rotation proof, 
because the resection had 
been performed transversely 
instead of obliquely. a b 
Illustration l63» 
Delayed healing of a fracture of the lower 
leg of the 36 year old patient E.P. after 
an accident. 
a) Condition after closed marrow nailing 
and resection of the fibula. 
b) Condition 3 months after marrow nailing. 
The fibula was resected at the same time. The patient 
could get out of bed 8 days after the operation. Then, the 
bridging over by bone took 2 months. Thereafter, the frac- 
ture was completely consolidated by bone in a favorable 
position. 
The 44 year old patient H.S. was an example for the 
femur. He sustained a fracture of the femur in a traffic 
accident. After 8 weeks of plaster cast treatment, the 
roentgenogram showed no callus at all. This was, hcwever, 
not the only indication for marrow nailing, but the unsatis- 
factory position of the fracture as well. The marrow nail 
was inserted, though the form and the position of the frac- 
ture were not particularly suitable for doing so. The frac- 
ture was located much to the distal side, in addition, a 
large third fragment had broken out. The marrow nailing was 
performed, operatively from the first, since only an opera- 
tive reduction appeared possible. During the operation no 
callus was observed. After the operation, an infection set 
in with fever and marked suppuration, which lasted 8 weeks. 
The patient got out of bed o weeks after the operation. The 
fracture healed with consolidation by bone. Eight weeks 
later the wounds had completely healed. 
Marrow nailing practically always stimulates the form- 
ation of-callus (see chapter III). With a pseudarthrosis, 
there is, in addition to this, the piercing of the bone caps and the drilling open of the marrow cavities. This usual- 
ly requires a considerable display of force and energy, so 
that the progress of the callus mechanism is guaranteed. 
For this reason, marrow nailing usually will do even in 
case of pseudarthroses, though one sometimes likes to add 
a moderate splintering up of the fracture end according to 
KIRSCHNER, by slightly opening the bone ends with a chisel. 
One must be cautious, however, not to force open the mar- 
row cavity'too much. The nail may loose its firm position 
altogether, such as at the distal end of the femur (see 
illustration 164). 
a be 
Illustration 164. 
Diagram of a femur pseudarthrosis in the 
lower third. By splintering the distal 
fracture end, the marrow nail would lose 
all support. 
In such a case, one would restrict oneself to a moderate 
splintering of 1 cm. length or even desist from it altogether, 
since any considerable shortening of the lower extremity must 
be avoided at all costs. Also here, a freshening of the bone 
surface itself by removal of the connective tissue is usually 
sufficient. In this case, the author recommends Luer's ron- 
geurs, with which the bone ends are bitten off, as it were. 
In the majority of pseudarthroses of the lower extremity, he 
even did not remove the connective tissue at all and only 
drilled the marrow cavities open. 
With a small number of marrow nailings of fractures with 
delayed healing, the intervention is possible without any 
operative opening of the fracture, viz., if there is no con- 
siderable dislocation and the marrow cavities approximately 
confront on© another* In other oases old dislocations exist which can be removed but seldom. Then, one must use an osteo- 
clast in most cases. The author has used osteoclasts of RIZ- 
ZOLI, ALSSBERG and PHELPS-GOCHT and found them all suitable, 
(soe illustration 165). 
Illustration 165» 
Reduction of an old dislocation with an 
osteoclast according to PHELPS-G-OCHT for 
the percutaneous marrow nailing in the 
case of a delayed healing of a fracture. 
It is by no means advisable to try for any length of 
time to enforce a closed marrow nailing in a case like that. 
This only leads to injuries of the extremity and loss of 
time, and eventually one has to open the fracture after all. 
Furthermore, it is by no moans advisable to nail a ful- 
ly developed pseudarthrosis without openingthe fracture cleft. 
MM——I ■ — - ~~ — ~ " * - 1 ' — - ~ II - - 
The marrow nail is not constructed to pierce the bone lids of 
the marrow cavities. One frequently has observed that it is 
extraordinarily hard to drill the marrow cavity open with a 
pointed awl, even if the bone caps seemed to be very thin in 
the X-ray. So one easily sees that the less sharp points of 
the nails can by no means pierce the bone by simply hammering 
them through. Intense hammering will therefore lead in such a case only to a bonding of tho nail and a shattering of 
the tissue of tho extremity. This more or less marked, ab- 
solutely useless, injury, can bo avoided from the first by 
beginning at once the inevitable operative opening of the 
pseudarthrosis. Tho operative technique on tho upper and 
on the lower extremity is difficult in principle. 
I. Marrow nailing of pseudarthroses of the lower ex- 
tremity. 
On principle, the technique here is in details the same 
as that of open marrow nailing of the respective bones des- 
cribed in this chapter, particularly since it is often not 
even necessary to remove the connective tissue from the 
fracture cleft as mentioned before. Also with regard to a 
possible necessary freshening of the fracture ends, the most 
important things have been mentioned, so that examples of 
the various forms of pseudarthroscs can be mentioned at once. 
The pseudarthrosis of the femur neck is suitably and 
successfully treated with the femur nock nail and thus it is 
not-within the scope of this book. As mentioned in chapter 
III, one may, in particular oases, give a more favorable in- 
clination to the fracture cleft by performing a subtrochan- 
teric osteotomy. This so-called PAUWEL-operation can be per- 
formed to advantage with marrow nails. It is described in 
the following section of this chapter. 
The subtrochanteric pseudarthrosis of the femur must 
be treated with the Y-shaped nail (see chapter V), sinoe 
the simple marrow nail cannot sufficiently be fixed because 
of the width of the marrow cavity in the trochanter mass. 
Even in those cases, the Y-shaped nail permits a good fixa- 
tion, since it is fixed the whole length of the femur nock 
by its transverse portion. 
We mention the example of the 36 year old patient W.L. 
Two and a half years ago, ho sustained a gunshot-fracture 
of the right femur, which, treated with a plaster cast, led 
to a sub-trochanteric pseudarthrosis. Three attempts had 
boon made to heal the pseudarthrosis; transplantation of a 
splinter, Book’s drilling and Kirschnor’s splintering, with- 
out any success. The knee and ankle-joint wore stiffened. 
The stiffening of adjacent joints, which was caused by the 
long fixation, considerably complicates the healing of psou- 
darthroses. It causes extraordinary long levor-arms, which 
increase many times the forces effective in the fracture 
cleft. A movable joint may protect the fracture from motion, 
a stiff one necessarily transfers every passive movement, as 
described in the example of the elbow-joint (see illustration 
166) . 
In this particular case, the pseudarthrosis cleft was 
opened. The cleft appeared to be a joint-cleft with smooth 
joint-planes. Marrow nailing was performed without any 
freshening of those planes. The healing course was normal. 
A fortnight after the operation, the patient could get out 
of bed, to which he had been confined for 2\ years. A fort- night later, he used his leg. 
The pseudarthrosis healed with 
firm bone in a favorable posi- 
tion (see illustration 167). 
The 23 year old patient 
W.W. had a pseudarthrosis of 
the middle of the femur after 
gunshot fracture. It had per- 
sisted for 2 years. During 
this period, the patient had 
a plaster cast. Since a'fistula 
existed, none of the usual ope- 
rations of pseudarthrosis was 
performed. Despite the fistula 
the marrow nail was inserted. 
This procedure is described in 
detail in the following chapter. 
The healing course was without 
complications. Seven weeks later, 
the patient could get out of bed. 
The extremely movable pseudar- 
throsis had become fixed by bone. 
The operation lasted 7 minutes 
(see illustration 168JT 
The 45 year old patient J. 
Sch* had a year old pseudar- 
throsis of t he femur after gun- 
shot fracture. A wire suture 
had been made without any suc- 
cess. There was a fistula too. 
The case was rather unfavorable for marrow nailing,because the 
pseudarthrosis was located far to the distal end. The knee, 
however, had already become completely stiff, so that a simple 
nail could be used, which was fixed by introducing it deeply in- 
to the knee-joint. The healing course was normal. Even 3 weeks 
after the marrow nailing, the patient could get out of bed (see 
illustration 169). 
Illustration 166. 
Diagram of the transfer of a 
passive movement of the fore- 
arm on a fracture of the upper 
arm and a stiff elbow-joint• 
Movable joint does not trans- 
fer this movement to the frac- 
ture site. 
a b 
Illustration 167* 
Two and a half year old subtrochanteric 
pseudarthrosis of the 36 year old patient 
W.L. after gunshot fracture. 
a) before marrow nailing 
b) after marrow nailing. abed 
Illustration 168. 
Very movable 2 year old pseudarthrosis 
of the middle of the femur after gun- 
shot fracture of the 23 year old patient 
W. W. 
a) before marrow nailing 
b) immediately after marrow nailing 
c) after 4 months, 
d) after removal of the nail after 6 months 
Illustration 169* 
Pseudarthrosis in the 
distal third of the 
femur after gunshot 
fracture. Patient J. 
Sch. age 45 years. 
The pseudarthrosis 
was ij year old. 
a) before marrow nail- 
ing 
b) immediately after 
marrow nailing 
c) six months after 
marrow nailing At last, we mention some pseudarthroses of the lower 
leg. 
The patient 1. M. age $2, had a 3 year old pseudar- 
throsis with fistula of the right lower leg after an acci- 
dent. The course after the marrow nailing was normal. 
The pseudarthrosis was fixed without shortening in a favor- 
able position, since only one nail was inserted and no con- 
nective tissue was removed. Even the fistula closed, though 
only 4 weeks after the removal of the nail (see illustration 
170). 
a b 
Illustration 1?Q. 
Three year old pseudarthrosis of the lower 
leg in the upper third. Patient J.M., age 
52. 
a) immediately after marrow nailing 
b) after several months. 
The 2$ year old patient W. H. had a ij year old pseu- 
darthrosis, which had been operated several times without 
success. In this case, it was possible to freshen the pseu- 
darthrosis, since a shortening of 2-3 cm. did not matter, 
because the other leg had been amputated. So a step-like 
freshening in the form of a double step was made with a bow- 
saw. The healing course was without complications. Since 
the fracture was located far to the proximal end, the patient 
was allowed to get out of bed and use his leg only 10 weeks 
later. The fracture healed in a favorable position with a 
good fixation by bone (see illustration 171). 314 
a bo 
Illustration 171» 
One and a half year old pseudarthrosis 
of the lower leg after gunshot fracture 
of the 25 year old patient W. H. 
a) before the operation 
b) after freshening in the form of a 
double step, which was possible because 
of an amputation of the other leg, and 
marrow nailing 
c) after extraction of the nail. 
The 36 year old patient J.S. had a one year old pseu- 
darthrosis below the middle of the tibia, which had been 
caused by an accident. There existed a fistula. Several un- 
successful operations had been performed, the last a drill- 
ing during which the drill broke. During osteotomy no cal- 
lus was found, the drill" was removed. The healing course 
was normal. The pseudarthrosis was fixed by bone in a 
favorable position. Because of persistent intense suppu- 
ration, the patient could use his leg only 5 months later. 
After 6 months the nail was extracted (see illustration 172). 
The 18 year old patient G.K. had a year old, intensely 
suppurating pseudarthrosis in the distal third of the tibia 
after an accident. In case of many of these pseudarthroses 
near the ankle joint with marked suppuration, the upper and 
lower foot joints become completely stiffened and are often 
even fixed by bone. In those cases, it is possible to nail 
the pseudarthrosis from the distal end with temporary sepa- 
ration of the skin of the sole of the foot. This is the 
technique of the arthrodesis of the foot-joint, as des- 
cribed in chapter VIII# In most cases, a straight femur 
nail was inserted, though this often turned out unfavorably. 
This is no genuine marrow nailing, but part of the nail 
sticks only in the spongiosal bone of the distal end of the 315 
a be 
Illustration 172. 
One year old ps eudarthr osis of 
the tibia below the middle, of 
the 36 year old patient I.S. 
a) before marrow nailing 
b) after marrow nailing 
c) after extraction of the nail, 
6 months later. 
tibia, of the talus and of the calcaneus. The nails will 
work loose at this place, so a second nail must often be 
driven in besido the first. Persistent infections occurred. 
In one case, a fatal infection set in because of the in- 
stability of the osteotomy, as described before in chapter 
IV. For this reason, it is suitable to use instead of the 
femur marrow nail the foot-joint arthrodesis nail with a 
broad head, which is described in chapter VIII. 
In the present case, a long femur nail was used. High 
fever set in and persisted for weeks, and several times ab- 
scesses had to be incised in the area surrounding the pseu- 
darthrosis. At last, however, the pseudarthrosis became 
fixed by bone and the fistulae healed, so that the patient 
could use his leg 7 months later. After 5 more weeks, the 
nail was removed (see illustration 173). Illustration 173* * 
Pseudarthrosis, one year old, in the lower 
third of the lower log of the 18 year old 
patient G-.K# 
a) before marrow nailing 
b) marrow nailing from the distal direction 
c) after extraction of the nail after 6 months. Illustration 174 shows one more case of this kind. It 
is the case of the 23 year old patient-H. B., who had a 3 
year old. pseudarthrosis with fistulae, which had been un- 
successfully treated with drillings and plastics of bonesplinter. 
Illustration 174* 
Three year old psoudarthrosis 
of the lowor leg in tho cen- 
tral third with stiffening of 
the upper and lowor foot Jointa 
Severed uilsuocossful operations 
one of them a plastic of bono- 
splinter. 
a) before marrow nailing 
b) after marrow nailing 
o) after 6 months 
d) after extraction of tho 
nail, 7 months later. 
Despite the fistulae, marrow nailing was performed from the 
idistal' direction. Also in this case, several abscesses oc- 
curred, which necessitated frequent incision, so that this patient too, could use his log only after 5 months. It is 
true, ho suffered from abdominal typhoid in this period too. 
The final result, however, was healing by bone (see illustra- 
tion 174) •' 
In some of these cases, a second marrow nail was driven 
in to restore the stability, so that the nails were linked 
to each other through their slits (see chapter V). 
With the 42 year old patient K. I•, a pseudarthrosis 
with fistulao had existed after gunshot fracture in the 
lower third of the lower log with a 3 cm. long defect. 
There had been five operations without any success. The up- 
per and lower foot joints were stiffened by bone. The mar- 
row nail was inserted from the distal direction. Also in 
this case, many abscesses appeared which had to bo incised. 
Then, the lower log bent at the pseudarthrosis site in the 
nature of a bandy log, nor was the osteotomy site rotation- 
proof any longer. Thereupon, a second nail was driven in, 
and the pseudarthrosis became fixed by bone. The patient 
could use his leg however, only 8 months later (see illustra- 
tion 175) . 
a b e c 
Illustration 175» 
Pseudarthrosis of the lower third of the tibia 
of the 42 year old patient K.J. after gunshot 
fracture, 2 years old. 
a) before marrow nailing 
b) after marrow nailing 
c) healing by bone, 8 months later. 
In this case, the fibula had been resected during the 
preceding operations. It was resected this time as well, 
since the fibula is generally resected during all osteotomies 
oh the lower leg, as described before. II. Marrow nailing of pseudarthroses of the upper ex- 
tremity. 
In the lower extremity, the pressure of the musculature 
and in walking the weight of the body as well are strong 
enough to guarantee a sufficient stability of the osteosyn- 
thesis and to press the fragments against each other when, 
some weeks later, the marrow nail is loosened by resorption 
around the nail. In the upper extremity, this is not true 
any more in case of most pseudarthroses. The considerably 
weaker musculature is usually so much weakened by prolonged 
fixation in a plaster cast, by operations and infection 
that it is no longer capable of pressing the fragments a- 
gainst each other along the marrow nail to a sufficient 
degree, particularly since the bone is often shortened, in 
addition, during the operation. On the contrary, the weight 
of the distal part cf the extremity draws the fragments wide 
apart. HAEBLER has observed this even in case of a fresh 
fracture of the upper arm (see illustration 1?6). 
a b 
Illustration 176, 
Marrow nailing of a pseudarthrosis of the 
upper arm. 
a) immediately after the operation 
b) after 2 weeks. The ends are wide apart 
through the pressure of the tissue and 
the weight of the extremity. Even if the 
gap is comparatively small, no bridging 
over by bone will occur. 
This is shown by the case of the 21 year old J.B. Hero, 
the pseudarthrosis cleft was so small that it seemed justi- 
fied to try a simple marrow nailing first, particularly since the cleft ran in an oblique direction (see illustration 177)* 
a b c 
Illustration 177• 
One year old pseudarthrosis of the 
ulna after shell splinter injury, 
with the 21 year old.patient J.B# 
a) before narrow nailing 
b) afterwards; despite favorable con- 
ditions a complete failure has oc- 
curred 
c) after extraction of the nail, 3 
months later. No bridging over 
by bone 
Despite the favorable conditions of this case the re- 
sult was a complete failure. It is absolutely wrong to treat 
pseudarthroses of the upper extremity, particularly of the 
forearm by marrow nailing in this way.It is, however, 
equally wrong to make the nail responsible for the failure. 
The cause is rather the described condition of the muscu- 
lature, and the best evidence for the correctness of this 
opinion is the fact that all pseudarthroses were fixed with- 
out any exception, if the tendency of the fragments to 
separate was removed. There are five methods by which this 
tendency may be overcome: 
1. The resection site is resected in a step-like manner. 
It is always advisable to make a freshening or even extensive 
resection on the upper extremity, since a shortening does not 
matter, as described in the beginning of this chapter. The 
steps are joined by a thick Kirschnor wire drilled through 
the bone in a direction transverse to that of the nail. The 
ends of the wire are bent down* Disadvantages; In case of marked suppuration the wire 
cuts, so- the steps of the resection must be made large 
enough. The method can be used only with the upper arm. 
To remove the contrivance, both the place where the nail 
was driven in and the 2 places where the wire was bent 
down must be reopened, 
2. Special springs according to MAATZ. MAATZ replaces 
the lost "drawing" effect of the muscles, as it were, by 
wire springs, which are inserted in the marrow cavity be- 
side the nail. The ends of the helical springs are pro- 
vided with small metal hooks, which are fastened to the 
holes in the corticalis of the two fragments, at a great 
distance from the osteotomy site. The hooks are broad 
lest they cut the bone in the presence of an infection. 
Disadvantages: The hooks are hard bo insert. Two 
more operative incisions must be made to insert them. 
It is even more difficult to find them again. That is 
practically possible only with a high frequency metal 
searcher such as developed by KUENTSCHER. In addition, 
it is usually hard to apply the wire traction in the mar- 
row cavity. The springs break easily and are hard to ex- 
tract because of cicatrization. 
3* The bending down of the nail according to the author, 
ThisTs the most simple method, but practical only on the 
humerus and ulna. It will do at all events, as shown by ex- 
perience, since it is sufficient to hold a fracture together 
by shortening of a bone. With the ulna, a simple marrow 
nail is driven in at the proc, styloideus, so far through 
the proximal fragment that its point protrudes from the ole- 
cranon, Then, a femur nail is pushed over each end of the 
nail till it touches the bone with the assistant pressing 
the forearm firmly together in the sense of a shortening, and 
the operator bends the protruding ends of the ulna nail down 
to an acute angle by using the femur nails as long levers. 
This is an immensely powerful union, which does not cut the 
bone very much, even in case of marked suppuration, because 
of the thickness of the nail. It may be used with the upper 
arm as well. Then the nail is inserted as usual from the 
distal side, but, at the same time, a marrow nail is driven 
in from the other typical place proximally at the outside of 
the upper arm (see chapter V) , though only a few centimeters 
deep, because it servos only as a guide rod for the point of 
the other nail. One may also proceed the other way from the 
proximal to the distal side. When a sufficiently large hole 
is drilled above the upper arm, the point of the nail appears 
in this hole. The nail is bent down in the same way as 
the ulna nail. 
Disadvantages: In order to remove the marrow nail, two 
wounds must bo reopened. However, it is easy to locate the 
nail. One of the bent down ends must be cut then with a 
powerful pair of forceps, or it is broken by bending it back 
and forth, 
4« The marrow screw according to the author. The nai1 
is thickened at its head and lies with tnis unickening in 
the distal end of the ulna, where the marrow cavity is al- 
ways broad as contrasted to the middle. At its point, it is provided with a nut, which is screwed in with a long 
wrench from the direction of the upper arm. As the marrow 
cavity is broad at that place too, a strong nut finds room 
in it. By tightening the nut, the osteotomy seam is strong- 
ly pressed together. The advantage of this method as con- 
trasted to the two mentioned before is that the whole mech- 
anism of the osteosynthesis is located within the marrow 
cavity and thus, an important principle of marrow nailing 
(chapter II) is fully observed. The screw may also be re- 
adjusted . 
Disadvantages: Two incisions are necessary to remove' 
the contrivance, though only those usual for marrow nailing 
of the ulna (chapter V)• 
5. The olive-wire according to POHL. POHL has described 
thick wires with an olive-like bulge at the end of the cali- 
ber of the marrow nail used. The end in the form of an olive 
is inserted first, then the nail. Thereafter a pierced olive 
is pushed on the wire and pressed into the marrow cavity by 
means of a screw or a helical spring. The osteotomy seam is 
pressed together by a screw, or, if necessary, with insertion 
of a helical spring. The advantage is that the same wound is 
used both for insertion and removal of the contrivance and for 
the nail and that the compression starts from the marrow cavi- 
ty. 
Disadvantages: The insertion of the contrivance is some- 
time n i c a 11 y . 
The resuJtsof these 5 different methods are approximately 
of the same value. The author did not observe any failure 
in any of them. With the helical spring, it was sometimes 
necessary to readjust the wire. With the bending down method 
healing appeared t-o be most prompt. This is the only method 
which really effects a rotation-proof union. The wires are 
not rotation-proof themselves. They prevent rotation only 
by pressing the bone ends firmly on each other. For this 
reason, the bone ends must be shaped accordingly. So it is 
once more emphasized that only oblique or even step-like 
osteotomy sections are practical; with the upper arm aTso 
to take advantage of the splintering of the bone ends in 
such a manner that the splinters remain in connection with 
the peri osteum and musculature.." ~ 
These five methods are first schematically represented 
in illustration 178 and then practically described by some 
examples. 323 
Illustration 17B« 
Schematic representation of the 5 methods 
for shortening of the separation of the 
bone ends during marrow nail osteotomy of 
the forearm. 
a) transverse wire according to KUENTSCHER 
b) helical wire according to MiJ.TZ 
c) bending down of the marrow nail accord- 
ing to KUENTSCHER 
d) marrow screw according to KUENTSCHER 
e) olive wire according to POHL. 324 
Examples for pseudarthroses of the upper arm. 
The 36 year old 0.0. had a year old psoudarthrosis in 
the middle upper arm after injury by a bazooka (Panzerfaust). 
Method 1 was used. No splint was applied, but active exor- 
cises were started 8 days later. Even within 6 weeks enough- 
callus had been formed. The fracture was fixed in an ideal 
position. After 3 months the nail was extracted (see illus- 
tration 179). 
Illustration 179* 
One yoar old psoudarthrosis 
of tlio uppor arm of the 36 
yoar old patient 0. 0. af- 
ter injury by a bazooka. 
a) before the operation 
b) after marrow nailing 
according to method 1 
(KUENTSCHER) 
c) after six weeks 
d) after extraction of the 
nail 3 months later. 325 
The case of the 50 year 
old patient O.T. is an example 
of marrow nailing according to 
method 2. The pseudarthrosis 
of the middle of the left up- 
per arm had been caused by an 
accident and had been operated 
16 times without any success, 
which had caused a shortening 
of 9 cm* The pseudarthrosis 
had persisted through 8 years. 
After the operation, an abduc- 
tion splint was applied for 6 
weeks for security. The heal- 
ing was delayed, but after 12 
weeks sufficient callus had 
formed. The pseudarthrosis 
was fixed by bone. Shoulder 
and elbow rjoint Wore not limit- 
ed in motion (see illustration 
180) . 
b o 
Illustration ISO. 
Eight year old pseudart hr o sis of the left 
upper arm after accident of the 50 year old 
O.T. which had boon operated 16 times in 
vain. 
a) before narrow nailing 
b) after marrow nailing according to method 2 
(MAATZ) 
c) subsequent to extraction.of the nail after 
4 months. The 41 year old pat lent F.Y. had a 2 year old pscu- 
darthrosis located high in the upper arm with narked sup- 
puration after a gunshot fracture. Method // 3 was used. 
Because of the suppuration, an abduction splint was ap- 
plied for 8 weeks. After o ■weeks, a sequestrum the size 
of a hazel-nut was removed. At the same time, the wire 
spring had to be tightened, since the small hook had cut 
the suppuration. The application of the spring 
traction at the head of the nail was effected by a broad 
calotte, in orddr to prevent safely any cutting into the 
massive tubcrculum majus. The final result was excellent. 
The pseudarthrosis was fixed by bone in a favorable posi- 
tion. The fistula© closed (sec illustration 181). 
a b c 
Illustration lei. 
PscudarthrosTs of tho upper third of the 
upper am of the 41 year old patient P.V. 
after gunshot fracture, 2 years old, with 
pronounced suppuration. 
a) after marrow nailing according to method 3 
(MAhTZ) 
b) after 8 months 
c) after removal of the nail after 12 
months. 
The 33 year old patient H.B. had a pseudarthrosis of 
the middle of the upper arm after an accident. It had been 
unsuccessfully treated Ij years in a plaster cast and by 
3 operations. Method § 3 was applied. The healing course 
was without complications. No splint was applied. The re- 
sult was absolutely firm union by bone in a favorable po- 
sition with only slight reduction of movability of the ■' 
Joints, which had been caused by the preceding treatment 
and considerably improved after the marrow nailing, so that 
exercise of movement could be started within 3 weeks after 
the operation (see illustration 182). a 
b c 
Illustration 182. 
Pseudarthrosis of the middle of the upper am of 
the 33 year old patient H.B. after accident, l£ 
year old. 
a) before the operation 
b) after 6 weeks 
c) after extraction of the nail, after 9 months. 32 8 
Examples for pseudarthroses of the forearm. 
Because of the special mechanical conditions, the heal- 
ing of pseudarthroses of the forearm is particularly diffi- 
cult, The fracture ends are subject to a great tendency to 
rotation. In addition, the bones of the forearm have only 
a small power of regeneration, they form only a little cal- 
lus. Unsuitable fixation will promptly damage the complice- 
ted system of muscles and sinews. 
The implantation of large bone splinters according to 
LEXER requires a long period of fixation, which is not ap- 
plicable in cases of pseudarthroses with fistulae. A par- 
ticularly long protective term must be observed in this 
case. As shown by experience, even then the splinters do 
not heal in, because the tissue is damaged forever by the 
shook wave of the modern missils (see also chapter VII). 
In addition, there are today the consequences of a long nal- 
nutrition which considerably reduce the power of resistance 
of the organism against infections. This corresponds to ex- 
perience also in other fields of surgery. Thus, according 
to the latest publications of FROMME, the rate of infections 
after hernia operations has increased enormously. The author 
considers this from the first and uses no bone splinters, be- 
cause tife success of the operation is void, if infection de- 
velops (EDITOR’S NOIE: Here KUE'NISCHER speaks of conditions 
current since the end of tte war). This does not apply to the 
marrow nail, it is true. Even cases with.fistulae can be 
nailed, as described in the following chapter. If there is 
a defect of one bone of the forearm, the other bone is 
shortened the same amount. If a pseudarthrosis of both bones 
exists, both bones' are shortened as much as necessary to 
freshen the pseudarthrosis and to perform oblique sections. 
Since the bones of the forearm are liable to splinter, the 
use of a chisel is vvrarned against. 
First we wish to describe the further course of the 
case represented in illustration 177, in which the ulna 
pseudarthrosis did not heal through simple marrow nailing. 
The forearm was shortened for 3 cm. by oblique osteotomy. 
Also the ulna was shortened at the osteotomy site and the 
osteotomy site compressed, by use of a spring (method 1). 
Thereupon, the pseudarthrosis healed; (see illustration 183). 
The 20 year old patient U.U. had a 3 cm. long defect 
of the left radius after shell splinter injury. The pseu- 
darthrosis had existed for 2h years. The ulna was shortened 
by 6 cm. and an ordinary nail inserted. An olive-wire was 
attached to the radius. The pseudarthrosis healed by bone 
in a favorable position. Ten months later, the nail was re- 
moved. a 
b 
Illustration 183. 
The sane ulna pseudarthrosis as represented 
in illustration 177 • 
a) two months after narrow nailing 
b) after extraction of the nail after 
six months. 
The 38 year old patient W. S. 
had a Ij year old psoudarthrosis, 
after shell splinter injury. The 
radius was shortened by 3 cn. and 
nethod # 5 used with the radius. 
The result was healing (see il- 
lustration 184). 
184a b o 
Illustration 184. 
One and a half"" year old pseudarthrosis of the 
ulna after shell splinter injury of the 38 year 
old patient W*S. 
a) before marrow’ nailing 
b) after 2 months, radius shortened by 3 cm. 
and an olive wire inserted in the radius. 
c) after extraction of the nail, 6 months later. 
The 28 year old patient 
P»G* had suffered for lg 
years from a 2 ca, long de- 
fect of the radius with 
synostosis between radius 
and ulna at the pseudar- 
throsis site following a 
gunshot fracture* The ul- 
na was shortened by 4 cm. 
and fixed in its position 
by bending the nail down. 
The synostosis was removed. 
The pseudarthrosis healed ‘ 
firm by bone in a favor- 
able position (see illu- 
stration 185). 
185a b c 
Illustration 185. 
Defect pseudarthrosis of the radius of the 
28 year old patient P.G. 
a) before marrow nailing 
b) after resection of the ulna for 4 cm. 
union of the ulna by bending down the 
ends of the nail (method jj 2) 
c) after removal of the nail after 6 months. 
The marrow nail was re- 
moved after 6 months by straight- 
ening the bent end at the ole- 
cranon and extracting the nail 
distally. 
With the 25 year old patient 
W.P., the forearm was in an al- 
most rectangular position at the 
margin of the proximal third. 
The ulna had firmly healed by 
bone, but was eburnized at the 
place of fracture and there was 
no longer any marrow cavity. 
The radius showed a pseudar- 
throsis (see illustration 186.) 
186a b o 
Illustration 1B6. 
Pseudarthrosis of the radius. Ulna of the 
25 year old patient W,F. healed with marked 
angulation. 
a) before marrow nailing 
b) after resection of the ulna by 7 cm. 
c) after extraction of the nails after 
6 months. The radius head was resected. 
Example for the method described under #2. The ebur- 
was resected for an extent of 7 cm. 
but the extra callus masses were left on both bones, so that 
the forearm looks in the X-ray immediately after the oper- 
ation as if the osteotomy site were already bridged over by 
bone. Despite the marked shortening of the ulna by 7 cm., 
the forearm was not much shortened by the osteotomy, as the 
operation put the arm in a straight position and thus, the 
seeming shortening was removed. 
The 21 year old patient J,B, had a pseudarthrosis of 
the left radius after shell splinter injury for 2 years. 
Because of the closeness to the wrist, the pseudarthrosis 
itself was not suitable for marrow nailing, since the mar- 
row nail could not be fixed in the short distal fragment 
(see chapter V). Even in this case, the principle of 
shortening was observed, the ulna shortened by marrow nail- 
ing by 3 cm. and an olive wire inserted. Then, the proxi- 
mal fragmert of the radius was freshened and stuck into 
the distal fragment, which had been splintered before, A 
dorsal plaster splint was applied, as in case of a frac- 
ture of the radius. During all other osteotomies of the 
upper arm and forearm described above, no plaster cast whatsoever was used. Only in times where a fever existed, 
an additional fixation of the joints was made during the 
period of the fever. An infection of the wound, with high 
fever, set in, and that surprisingly 6 weeks after the oper 
ation. Because of wrong bending of the nail before the 
nailing, the-tip of the nail lay close to the joint-cleft 
of the elbow, and pain and a hematoma were caused in the 
elbow-joint. Thereupon, the nail was immediately extracted 
and both, the place where the nail had been driven in and 
the osteotomy wound at the ulna were opened. Then, the 
fever decreased and the symptoms on the part of the joint 
disappeared. The joint remained freely movable. Because 
of the early extraction of the nail however, the radius 
pseudarthrosis was not healed, but an additional pseu- 
darthrosis was formed now at the resection site of the 
ulna by the separation of the bone ends. (See illustra- 
tion 187) • 
a be 
Illustration 187* 
Pseudarthrosis of the radius near the wrist 
after shell splinter injury, 2 years old, of 
the 21 year old patient I.B. 
a) before the operation 
b) after marrow nail shortening-osteotomy 
of the ulna by 3 cm. Method jf A. The 
tip of the nail endangeres the elbow- 
joint. (The white line: is an artefact 
caused by the X-ray film having been 
torn; 
c) for this reason, the nail has been re- 
moved, and an additional pseudarthrosis 
has now developed at the resection site 
of the ulna. 334 
Thereupon, a piece 
of the radius was resec- 
ted in the middle and 
both bones were nailed 
which made both pseu- 
darthroses heal com- 
pletely. The nails 
were removed 12 months 
after the first oper- 
ation (see illustration 
188). 
The 28 year old pa- 
tient H.H. had also a psen- 
dor throsis of the radius 
after shell splinter injury 
located far to the distal 
end. The pseudarthrosis was 
extensively splintered with 
a chisel and firmly united 
by resection of the ulna 
amounting to 3 cm. Thus,the 
present manus vara was also 
corrected. The pseudarthrosis 
healed firmly by bone (see 
illustration 189)• 
Illustration 188. 
The same case as represented in illustra- 
tion 18?. Both pseudarthroses were healed 
by one more resection of both bones, 
a) after the second marrow nailing 
b) after removal of the nails, 12 months 
after the first operation. Illustration 189» 
Distally located pseudarthrosis of the 
radius after shell splinter injury) 28 
year old patient H, H. 
a) before the operation 
b) after marrow nailing osteotomy shorten- 
ing the ulna by 3 cm, and splintering 
of .the pseudarthrosis, 
c) after extraction of the nail after 3 
months. 
Tho last example of a very distally located pseudar- 
throsis is the case of the 22 year old patient B,H, The 
ps eudarthrosis had existed for Ij year and caused consider- 
able complaints. It was nailed in a fistulating condition, 
and ring-sequestra appeared at the places of resection (see 
chapter IV). Nevertheless, the pseudarthrosis became firm 
by bone. 
The nail moved into the elbow-Joint. Thereupon it was 
drawn back. No infection of the joint developed. This is 
certainly tho best proof that tho infection doesbnot at alit- 
or at least not very quickly run along the nail, if the pus 
is not under pressure and if the nail is firm enough. 
In the majority of these pseudarthroses, a considerable 
stiffening of the joints of tho forearm existed, owing to the 
preceding long fixation in plaster cast or splint before tho 
marrow nailing. In most oases, marked improvement could be obtained due to the possibility of early motion after mar- 
row nailing. Even in the cases with infection, no marked 
reduction of mobility because of the operation could be 
observed* 
In one case, a complete stiffening of the formerly on- 
ly half-stiffened elbow-joint occurred, but it can be re- 
garded as a consequence of the resection of the radius head, 
and the marrow nail cannot bo made responsible for it* 
It was a psoudarthrosis of the radius at the border 
of the proximal third, which had been operated several 
times without any success. Movements of pronation and su- 
pination were possible only in the form of shaking move- 
ments. Flexion and. extension in the elb ow-joint were re- 
duced to about 50 c/o. The psoudarthrosis had developed 
after a shell splinter injury and was 1 year old. The 
radius head was resected in the typical way (see chapter 
IX). The radius was nailed subsequently. An infection 
of the osteotomy site developed, which spread to the re- 
section site and thus to the joint. The infection took 
a mild course, but caused & complete stiffening of the 
joint,- For this reason, the resection of the radius head 
should, if possible not be temporally combined with mar- 
row nailing, but an interval of about half a year should 
be allowed until the marrow cavity of the radius is safe- 
ly separated by bone from the elbow-joint. 
In peacetime surgery, where the danger of infection is 
not so important, it is, of course, quite possible to com- 
bine marrow nailing with bone grafting according to LEXER 
or with the spongiosa transplantation according to MATTI, 
as ZENKER has done. In a similar way as described with the 
lengthening osteotomy of the femur H. REICH placed a piece 
of the fibula on the marrow nail with a defect pseudarthrosis 
of the forearm and was successful, though it is generally 
not advisable to use this method with the forearm. The ro- 
tation strain of the osteotomy site is enormous and the dif- 
ficulty of rendering the osteotomy site rotation-proof is con- 
siderably increased by bone-grafting. For this reason, it 
should be considered only in exceptional oases with very 
large defects. This is done safest with transplantation 
under the abdominal skin, as described earlier. But this 
procedure takes much time and is inconvenient to the pa- 
tient. Absolutely certain and most simple at the same time 
is the described shortening-osteotomy with marrow nail union 
in the sound bone. 
if. Marrow nail osteotomy with deformities* 
1* The subtrochanteric osteotomy* 
In case of congenital dislocations of the hip-joint, 
the indication for this operation is most frequently present* 
This operation corrects the existing abduction contraction 
and thus the seeming shortening of the leg as well* In ad- 
diti on, by obtaining a position of abduction, a shift of the 
total muscular pressure in the direction of the articular 337 
socket is obtained, which corrects or even removes tho 
tendency of a dislocation from the articular socket. 
The operation corrects at the same time, the usually ex- 
isting flexion contraction of the hip. 
Another more rare indication is a hip stiffened by 
bone in an unfavorable position. At least, the PAUIVEL 
operation, which has boon described already in chapter 
III, must be mentioned. Its objective is to tarn tho un- 
favorable vertical fracture cleft of tto femur neck pseu- 
darthrosis into a more favorable one. Several suggestions 
of performing tho section have been made. The technique 
of SCHAKZ and the bifurcation according to LORENZ arc best 
known. The hazard of the previous methods is tho slipping 
off of tho bone ends, which may cause disagreeable pseu- 
danthroses. This hazard may be safely avoided by using 
marrow nails. 
There are two methods of marrow nailing; the sub- 
trochanteric osteotomy with tho bent marrow nail accord- 
ing to tho author and that with an angular marrow nail ac- 
cording to GUETTNER. The bent nail permits a very tfstable 
osteosynthesis”, since it is held by longitudinal-elastic 
forces. The nail is uniformly bent and broader at its 
head than at its point. The point is flattened at the con- 
cave side of the nail. The ordinary straight marrow nail 
is hold by elastic forces working transversely to its 
longitudinal axis. The bent marrow nail touches the bone 
at 4 points, and, after firm driving in, is elastically 
fixed by its slight extension, thus extending the bone as 
well. This is schematically demonstrated in illustration 
190. 
Illustration 190* 
Diagram of tho fixation of 
tho marrow nail by elastic 
forces. 
a) with the straight narrow 
nail, tho bonding of the 
transverse section is 
compressed; 
b) with the bent nail, 
bonding in its longi- 
tudinal direction. 338 
The technique of the subtrochanteric osteotomy then 
is as follows: The patient is laid on the side of the sound 
leg with moderately flexed hips. An incision of the skin is 
made which extends from the tip of the trochanter major to 
about below the trochanter minor, so that the place where 
the nail is driven in and osteotomy site are united in one 
wound. Then, as usual during SCHANZ’s osteotomy, the bone 
is cut about 2 cm. below the trochanter minor and an ex- 
actly calculated wedge is cut out, the base of which is 
lateral and anterior. The size of this wedge depends on 
the size of the intended angle of correction. The wedge 
is measured best after an X-ray tracing. Then, a hole is 
drilled in the trochanter tip in the exact direction towards 
the osteotomy site with an awl and the nail is inserted in 
this hole, until its point appears in the osteotomy site. 
This point is then stuck in the distal bone fragment • There- 
upon, the leg is extended and lifted and the nail is driven 
in finally. Then the skin is sutured and a drain left in 
place for 24 hours. The union is so stable, that the leg 
can be used a fortnight later. Marrow nails of various 
thickness and curvature must be available. 
The method is now demonstrated by 3 examples; 
The 16 year old S.S. had a congenital hip-luxation with 
dislocation of the articular socket and a marked adduction 
contracture. The operation was performed as described a- 
bove, after an X-ray tracing had been made (see illustration 
191). 
191 a 
191 b 
After insertion of the nail, the intended position 
of abduction and extension was exactly established. The 
operation lasted 16 minutes. The healing course was with- 
our complications. The patient could get out of bed and 
walk after a fortnight. The TRENDELENBURG phenomenon was 
removed. The nail was extracted after 1+ months. There was 
an excellent formation of callus. No atrophy of muscles or 
joint-stiffening occurred (see Illustration 191) c d 
Illustration 191. 
a) Congenital hip-luxation of the 16 year old 
patient S. S. 
b) Two X-rays laid on each other for measuring 
the size of the bone wedge which is to be 
cut out. 
c) after subtrochanteric osteotomy and nailing 
with a bent marrow nail. Contractions of 
abduction and angulation are corrected. 
d) after extraction of the nail after 16 weeks. 
Illustration 192 shows an example of the use of a bent 
nail wl th a hip stiffened in adduction after infected arthri- 
tis of the 32 year old patient H.A. 
Illustration 192. 
Subtrochanteric osteotomy of the hip-joint 
stiffened in adduction. At rast we demonstrate the application of Pauwel’s 
operation, using the marrow nail: 
It was a 2 year old pseudarthrosis of the femur nbck, 
with which an unsuccessful attempt at nailing the femur 
neck had been made before. It was >a medial fracture. The 
patient was 37 years old. With pseudarthroses like that 
the best results are obtained with the Smith-Petersen nail. 
In this case, however, there existed a considerable adduc- 
tion contracture during the operation so that the subtrochan- 
teric osteotomy in the sense of Pauwelfs operation appeared 
indicated. The operation could be easily performed; though 
the patient was very fat, the operation lasted about 12 
minutes only. The osteotomy healed without complications, 
but the pseudarthrosis did not, because the fracture slipped 
off. So an additional nailing of the femur neck was made, 
healing subsequently set in. 
The subtrochanteric osteotomy with an angular nail. 
Guettner proceeds in the following way: In the usual 
way, a guide rod is introduced under X-ray control and a 
thin marrow nail is driven in ov.r it. Then, the femur is 
exposed from the outside and out with a Gigli-saw. Then, 
a corresponding wedge is sawed out in front and at the out- 
side, and the leg is bent forwards and outwards, which makes 
the nail bend as well. Then, a drain is inserted and the 
wound is closed in layers. The leg is now fixed in a Braunfs 
splint. Four weeks later the patient can get out of bed 
without any additional plaster cast. Even in this form, 
the method saves the additional plaster cast. 
REICH proceeded in case of contractions of adduction 
and abduction of the hip by calculating the angulation 
previously. Then, he bent straight strong femur nails in 
a vise to the corresponding angulation. Then, the wedge 
was removed and these nails driven in in the usual way. 
Thereupon, the log adjusted itself automatically to the de- 
sired angulation, i.e. the leg raised when the adduction con- 
traction was removed, as the patient lay on his side (illus- 
tration 193) • 
a b 
Illustration 193* 
Angular nails to correct 
a) adduction 
b) abduction contraction. These pictures have been kindly made available to us 
by B. REICH (Only sketches could be made). 
2. Marrow nail osteotomy with bandy legs and 
knock-knee• 
The use of the method with traumatic bandy legs and 
knock-knees has been described in the preceding section. 
Almost all of them are sharp angulations, which can be 
ideally treated with marrow nails. T.uc non-traumatic de- 
formities, which are in most cases of rachitic origin, 
may be either similar angulations or bends in which the 
whole bone is-more or less involved. Also in case of very 
old fractures, the deformity gradually changes into the 
form of a bend. Since either the whole marrow cavity or 
greater sections of it are curved, it is difficult to use 
marrow nails. Thus, the first correction of bandy leg on 
the lower leg of a 2A year old man, that was performed by 
the author and GUENTZ was a failure. A wedge had been sawed 
out of the place cf the sharpest curve, so that the bone ends 
faced one another in the form of a transverse section. After 
a synthesis had been attempted, with a tibia nail,’the old 
curve reappeared. In one plane, the lav er leg nail is flex- 
ible, so that it is possible to insert it in the bone. With 
this plane, the nail shifted by rotation to the direction of 
the old curve and assumed this curve so that, after insertion 
of the nail, the lower leg again had the same form as before 
the operation. Later, the author avoided this rotation dur- 
a b 
Illustration 194* 
Vory curved rachitic bandy legs of the 
18 year old patient S. H. 
a) before marrow nailing 
b) afterwards, both legs are completely 
straight. ing the wedge-resection of the lower leg by driving in 
both nails at the same time. Herein he carefully saw 
to it, that the nails fitted well into the transverse 
section and were inserted so firmly that they could not 
rotate. Furthermore, the wedge was sawed out in a way 
that an oblique union-plane was formed. Thus, it was 
possible to permit the patients to got out of bed early 
without any plaster cast. 
As an example wo mention the 18 year old patient S.H. 
She had markedly curved lower legs in the farm of bandy 
logs. The cause had been rachitis (see illustration 194). 
The wedge had been so calculated that the existing in- 
ner rotation of the ankle joints was corrected as well. 
No plaster cast was applied. Both legs lengthened by 7 cm. 
each as a result of the straightening. 
According to the author, failures can also be avoided 
by the use of Helferichh; principle of oblique cutting, am 
we remind the reader of illustration 149, which shows the 
correction of a curvation of an old fracture, which is as 
flat as a rachitic deformity. In case of highly marked 
curvations, it is possible, too, in this way, to cut the 
bone at 2 different places with the counterincision saw. 
After correction of a bandy leg of a 19 year old girl, 
E. G-UENTZ observed a slipping off in the plaster cast despite 
V-shaped osteotomy according to ROEPKE, so he decided to per- 
form a late marrow na.iling. He used, however, only a broad, 
flexible lower leg nail and then bent the leg with the nail 
over a wooden wedge according to the procedure of MAATZ in 
case of late corrections of fractures. This is demonstrated 
schematically in illustration 195* 
111us tr a ti on 195* 
Diagram of the correction” of a bandy leg 
by bending the nailed leg over a wooden 
wedge. 
a) before the marrow nailing 
b) after nailing with a flexible nail 
c) after bending. 
Of course, an additional plaster cast must be applied 
to such a log, but it is possible to remove it much earlier 
than without marrow nailing. Thus exercise of movement can 
be started earlier and there need be no apprehension that a 
lateral dislocation might occur. To avoid a slipping off, GUENTZ recommends marrow nail- 
ing also during the supracondylar osteotomy. 
3. Supracondylar osteotomy by means of marrow nails. 
We do not speak of those cases in which in childhood on-r 
ly a chi sol-blow was done and the leg bent then in the nature 
of the described HOFFA’s osteotomy, because of bandy log or 
turned-in logs or flexion contractions. These cases heal ex- 
cellently in a plaster cast nor is the movability of the knee- 
joint endangered-with children. This is not true for the knees 
of adult persons, particularly if an operation is performed so 
close to the joint. Frequently, however, rotation deformities 
must be corrected at the same time. Then, the bone must be 
completely cut and there is the hazard of a .slipping off, par- 
ticularly with older children and adults. By soft part con- 
traction of these musouli gastrocnemii the distal femur end 
glides off backwards. 'Whoever does nor mean to correct the 
rotation fault does not so easily experience this incon- 
venience. The marrow nail can prevent it with certainty. 
The nail is not much supported in the spongiosa, but always 
lies eccentrically and is pressed against the compacts by 
the muscles so that it is rather well fixed. But this can- 
not be regarded as a "stable osteosynthesis" and an addition- 
al plaster cast is necessary also here, perhaps only in the 
form of a plaster sleeve. Even in this case, the advantage 
is that the cast can be removed early, as with the supracon- 
dylar osteotomy a long period of fixation is usually necessary 
because of the hazard of a refracture at this place. 
We mention some examples of GUENTZ for the demonstration 
of this procedure; 18 year old girl, right leg in valgus 
position. On 15 October 1942, supracondylar osteotomy. After 
sticking them into each other, the fragments were well fixed 
but elastic. Plaster cast without including the pelvis. 
Even on 5 November, the plaster oast was reduced to a splint 
and movements of the knee-joint were started. On 19 November 
the patient got out of bed with a removable plaster sleeve, 
so that she could continue to exercise the knee-joint. On 1 
December, no plaster sleeve and discharge from the hospital. 
On 11 January 1943, the nail was extracted. The ability to 
bend the knee-joint returned soon, but was still reduced for 
some months in its final motion, as a consequence of the ag- 
gravation of the gliding mechanism of the m. quadriceps 
caused by the formation of callus. As is well-known, this is 
an important reason why the f ormidable stiffening of extension 
of the knee-joint occurs after supracondylar osteotomies and 
fractures. To prevent that, early active motion of the joint 
is the most important remedy, but it is possibly only by fix- 
ation by marrow nails. GUENTZ ventured these exercises even 
after 3 weeks, in one case previously treated in the same way 
only after 5 weeks with the result that mobilization was as- 
sociated with considerable difficulties. Further experience 
must show whether a simple plaster sleeve is sufficient and 
whether patellar motion may then be started at once (see 
illustration 196). 344 
In the case of a 17 year 
old boy, the fixation by a 
nail during a supracondylar 
osteotomy because of flexion- 
contracture of the knee-joint 
owing to paresis of the 
quadriceps brought a con- 
siderable relief. The frag- 
ment sat firm at once, so 
that, without any regard to 
the osteotomy, the plastics 
of the quadriceps could be 
made out of biceps and 
sartorius and, after 5 weeks, 
exorcise could be started 
without plaster cast (see 
illustration 197). 
Illustration 196* 
Supracondylar osteotomy in 
an 18 y.-ar old girl because 
of valgus position of leg. 
Impaling of the distal frag- 
ment. Even after 3j weeks, 
beginning with movements of 
the knee-joint according to 
E. GUSNTZ. 
With a seven year old 
girl with turned-in leg po- 
sition the highest degree and 
dislocation of the axes be- 
cause of a congenital fibula 
defect, the osteotomy slipped 
off in plaster and could be 
held only by a second opening 
of the operative site and im- 
paling by a marrow nail. Ex- 
tensive contractures of po- 
sition like that should be 
operated accordingly on prin- 
ciple even in small children. 
If the knee-joint is 
completely stiffened, one can, 
with uso of a nail slowly passing through the knee, obtain 
a completely ”stable osteosynthesis”, which requires no plaster 
cast and permits the patient to got up a few days after the 
operation. We mention some examples of GUENTZ• 
Illustration 197» 
Supracondylar osteotomy be- 
cause of flexion contraction 
of the knee-joint owing to 
paresis of the quadriceps 
combined with plastics of the 
quadriceps. Start -of motion 
5 weeks after marrow nailing. Fifteen year old boy. At the age of 10, resection of 
the knee-joint because of incomplete stiffness of the joint 
after empyema. Despite (or because ot the now too small?) 
knee-shell, formation of an increasing flexion position with 
loosening of the femur epiphysis as seen in the X-ray. Flex- 
ion position 135 degrees. On 28 June 1943, osteotomy with 
insertion of a 55 cm. long nail.- In the lower leg, it lay 
involuntarily somewhat eccentric, so it pierced the corti- 
calis below the condyles and lay along the outside of the 
tibia wall. Complete fixation all the same. No plaster 
cast. On 12 July 1943 getting out of bed, on 23 July 1943 
discharge with a precautionary plaster-sleeve, since the 
boy did by no moans spare the log and was glad to be able 
to use it properly now. 
'With a 14 year old 
girl, too (illustration 
196), who had to be oper- 
ated for the same reason 
with a simultaneous cor- 
rection of the position 
of rotation, no plaster 
cast was necessary, and 
the patient was able to 
walk 2\ weeks later. 
4» Marrow nailing of 
ioot deformities. 
With foot deformities 
the method has been used 
comparatively seldom so 
far. 
GDENTZ reports about 
the following case; 
A 20 year old female 
patient with a left-club- 
foot, which had been oper- 
ated several times before 
and was now completely 
crippled. The consider- 
ably shortened posterior 
foot was stiff, the fore- 
foot was markedly supinated, 
the large too was angulated 
at a right angle to support 
the fiist metatarsal as in 
of a hammer-toe flat- 
i’eot. There were numerous 
pressure callosities on the lateral edge of the foot and on 
the dorsum of the large toe. Amputation was suggested, but 
refused by the patient. The objective of the operation was 
to turn, the first metatarsal down as a support without any 
greater intervention which would have deformed the foot even 
more. First, 2/3 resection of the base joint of the large 
too according to BRANDT, then osteotomy of the first and 
Illustration 198. 
Supracondylar osteotomy on 
a completely stiff knee- 
joint a 55 cm. long marrow 
nail. Patient; 14 year old 
girl. No plaster cast. Com- 
plete ability to walk after 
Sg weeks • 346 
second metatarsals at the base. In order to fix the po- 
sition of the first metatarsal, a small marrow'nail is 
driven in from the metatarsal head to the middle of the 
foot, without any respect to the small joints, but, as 
a precautionary means, an additonal plaster cast treat- 
ment was carried out. Surprisingly the large too was 
quite movable after 7 weeks, though the end of the nail 
protruded somewhat from the metatarsal heed. This was 
an attempt started owing to the peculiarity of the con- 
ditions. Its success affords justified hope for using 
marrow nails during forefoot operations of hollow and 
spraddling feet and similar deformities (see illustration 
199). 
Illustration 199• 
Osteotomy on the first metatarsal of a 20 
year old girl. Correction of an old club- 
foot with raised first metatarsal and hammer 
toe according to E. CUENTZ. 
G. Marrow nr.iling in case of bone tumors. 
Prophylactic marrow nailing. 
1. Marrow nailing of non-malignant turners. 
Considoring the facts described in this chapter, 
larrow nailing suggests itself after resection of non- 
lalignant tumors, and the method depends entirely on site 
md extent of the tumor and the affected bone. The tech- 
lique of marrow nail osteotomy is then just the same as 
[escribed in the sections on osteotomy and psoudarthroses. 
lie same advantages are present also here. They result 
*rom the durability, firm union, and early movability# 
Ivon in 1940, the author nailed tumors. One case was a 347 
six year old girl with a chondroma the size of an apple 
in the middle of the right upper arm, which was healed 
by continuity resection. In the second case, the 11 
year old boy H,P. a chondroma existed too. The condroma 
was subtrochanterically located and had caused a spon- 
taneous fracture. The boy had lain in plaster for 18 
weeks, but no sign of healing of the fracture could be 
observed. The tumor was the size of a walnut. It was 
scraped out and a marrow nail inserted. Even 3 weeks 
later, the boy could get out of bed. The nail was re- 
moved after 6 months. The bone had healed. A late ex- 
amination after lj years showed no symptoms of disease 
any more (see illustration 200), 
a be 
Illustration 200, 
Non-malignant tumor (chondroma) with spon- 
taneous fracture of the 11 year old boy H.P# 
a) before marrow nailing 
b) after scraping out of the tumor and marrow 
nailing 
c) some time later, sufficient formation of 
callus. 
BOEHLER describes an interesting case of his clinics; 
It was an ostitis fibrosa cystica localisata of a 32 year 
old woman. The cyst was 7 cm. long and was located in the 
upper third of the left femur. The wall was as thin as 
paper, EIGENTHALER performed a closed marrow nailing. Af- 
ter introduction of the guide fod (chapter V), the bone 
broke after a slight turn. The fracture cleft ran oblique- 
ly across the cyst. Thereupon, the nail was driven in with- out opening the cyst. The fracture caused a negligible 
shortening (6mm,), After the marrow nailing, the former 
tension pain had disappeared. After a fortnight, the- 
patient could Independently lift her leg from the bed, 
which had not been possible before the operation♦ After 
5 weeks, she got out of bed aid , after 6 weeks, she left 
the hospital without any complaints. After B months, the 
nail was removed under local anaesthesia. The cyst was 
no more recognizable in the X-ray. BOEHLER writes about 
this case: 
"The course of this case is the best proof 
that the ostitis fibrosa cystica localisata is a 
disease of the bone caused by tension. By the in- 
sertion of the marrow nail, the cyst was opened 
and its contents could drain constantly. In con- 
trast to a spontaneous fracture, the cavity wall 
could not close any more and so no new tension 
cquld develop. Since the pressure from the in- 
side was absent, the bone formed without impedi- 
ment. The healing was sped by the fracture caused 
by the drilling of the guide rod with opening of 
the cyst in the whole wall and by the slight 
shortening thus caused”. 
The otherwise usual therapy with scraping out of tho 
cyst and implantation of a large bone graft is a major 
operation* Oh the other hand, closed marrow nailing is a 
short and simple intervention, if performed by a skilled 
surgeon. The fine pictures which BOEHLER adds to the 
description of this case are convincing. Further ex- 
perience will show whether it is really possible in every 
case to make the ostitis fibrosa localisata cystica heal. 
At the suggestion of BOEHLERfs case, the author made a 
closed marrow nailing with the same disease, though the 
case was loss favorable, as a cyst the size of an apple 
in the femoral condyles was involved. Since the cyst 
was located far to the distal side, the draining path a- 
long the 42 cm. long nail was perhaps too long. It was 
the case of the 46 year old man K.F, who had suffered 
from complaints in the knee-joint for lg years. The roent- 
genogram showed a large cyst. A test excision was made 
first. The diagnosis was histologically confirmed by 
BUENGIER/Kiel. Also the closed marrow nailing was per- 
formed with the utmost care and a Volkmann's splint sub- 
sequently applied. The nail point stuck in the middle of 
the tumor. No success was obtained, however, but the cyst 
was at least tho same size after 6 months as before the 
operation. But the pain disappeared after the marrow nail- 
ing. As a matter of fact, no marked formation of callus 
can be expected in the spongiosa of the femur. In BOEHLERfs 
case, one can well observe the approach of callus from all 
tho compacta directions. Maybe, this is tho explanation of 
tho failure (see illustration 201), 
GRIESSMANN and SGHUETTEMEYER report about a brown tumor 
in the area of the trochanter minor of a 10 year old boy. 
The tumor had been discovered accidentally in the X-ray, 
One year later, a spontaneous fracture occurred at that 
place, following a minor trauma. No satisfactory position a be 
Illustration 201. 
Ostitis fibrosa cystica localisata 
of the 46 year old patient K. P. 
a) before the closed marrow nailing 
b) 6 months afterwards 
c) no succjss was obtained. 
could bo obtained with vire extension, etc, but a per- 
cutaneous marrow nailing without exposure of the fracture 
was successful. The fracture healed, and the nail could 
be removed even after 4 months. 
2. Marrow nailing of malignant tumors. 
Marrow nailing of maligiant tumors is now performed to 
an increasing degree. It has a precise indication. Of 
course,no one will pretend that the nail impairs the growth 
of the tumor. Its therapeutic effect is only symptomatic. 
We can eliminate the symptom of a spontaneous fracture. 
This is a great deal. It is often the only symptom of a 
malignant bone tumor or a malignant bone metastasis. Then 
wo can give the patients the illusions of being healthy 
again for a long time, but above all, it is possible to 
make the rest of their lives more comfortable. In the ma- 
jority of the cases, the spontaneous fracture is located 
in the area of the trochanter minor. This was stated, for 
instance, by UDSRSTADT at the suggestion of the author in 
a statistical synopsis of the clinics of Kiel. Why the 
bone tumors and the metastases of certain malignant tumors have a predilection for that very place is absolutely ob- 
scure. That the capillaries at this place are said to 
have a certain width as nowhere else in the whole body and 
that the cells circulating in the blood are said to stick 
just there, is not easy to imagine - easier that the power 
of resistance of the bone tissue against the settling down 
of tumor cells is there less great, since the bone is at that 
place exposed to a particular strain. At that place, the 
author was able to ascertain the mentioned (chapter III) 
whirl of force-lines. Also this attempt of explanation ap- 
pears to be quite strained. Anyhow, it is a fact that the 
tumors are located most frequently at that pMce and the 
patients have had to lie the la. st few years or months of 
their lives in a pelvic cast. This oast cannot be kept 
clean in the long run, however carefully it is applied. In 
addition, there is the hazard of a docubital ulcer, the 
weakening of the general condition by lying on the back, 
etc. and not least the mental suffering. 
The marrow nail liberates one from all this, even in 
those cases where there is no hope that the cleft of the 
spontaneous fracture might be bridged over by callus. Ex- 
perience has shown that the marrow nail can afford complete 
support to the bone, and we remember the patient of the au- 
thor described in chapter II, who rode IB km. every day on 
his bicycle after a femur osteotomy, though the fracture was 
not yet firm nor could be, since the operation had been per- 
formed only 3 weeks before. In this context, BOEHIER has 
pointed out those of his cases where he was able to show 
that people with nailed femur psoudarthroses are fully able 
for work, though the fracture is not firm at all. 
Only inoperable tumors can be considered for marrow 
nailing; also those cases in which the patient refuses the 
suggested amputation, which occurs quite frequently. With 
many bone tumors, the therapeutic value of the amputation 
is doubtful anyhow, so one often proposes amputation only 
with reserve. The motastases of malignant tumors may also 
be an indication, since they are almost always inoperable. 
Only few exceptions are known in literature. Thus, W. AM- 
SCHUETZ reports about 2 cases of bone metastases after the 
removal of a hypernephroma. In both cases, there was only 
one single metastasis and those were the only ones, after 
the removal of which the patients were regarded as healed 
for good. The intervention is usually performed in the 
form of closed marrow nailing. In some cases, however, one 
has to accept the exposure of the tumor, too. Then, a histo- 
logical examination may bo made to settle the diagnosis. 
This applies above all to tumors the nature cf which remains 
obscure as regards clinical history, clinical examination and 
impression of the roentgenogram. Then, the technique of mar- 
row nailing is the same as with osteotomies (see illustra- 
tion 202). 
Now the question is raised at once whether the nail 
fosters motastases considerably and thus shortens life. 
The nailing certainly seems to be an appropriate means 
to spread motastases artificially. a b 
Illustration 202. 
Example of the marrow nailing of a sub- 
trochanteric metastasis of a carcinoma 
of the breast. 
a) before marrow nailing 
b) after marrow nailing 
In many cases, one would risk even that to render an in- 
tolerable life tolerable again- Cases are known where such a 
spreading of metastases is distinctly recognizable in the X- 
ray. Thus, HAASE describes a case of subtrochanteric hyper- 
nephroma metastasis where, after marrow nailing, numerous in- 
oculated tumors the size of peas are visible in the X-ray a- 
long the entire length of the nail. Here, the nail has car- 
ried away the tumor cells and dispersed them over the whole 
marrow cavity. Also a case of the clinics of Kiel shows a 
similar spreading of metastases. It was a metastasis the 
size of a hen’s egg in the area of the trochanter/ after a 
bronchial carcinoma. The female patient J.S. was 45 years 
old. A marrow nailing and intense radiation by X-rays were 
pe rformed,•and the metastasis completely disappeared. One 
year later, however, new metastases appeared distally in the 
marrow cavity along the nail and did not cause any complaints. 
Since the marrow nailing, the patient could walk without pain 
and is now receiving X-ray treatment again (see illustration 
203) . 352 
c d 
Illustration 203« 
within 
the trochanteric area of the 45 year old 
female patient J.S. 
a) before marrow nailing 
b) after marrow nailing 
c) after 1 year 
d) after an intense X-ray treatment the primary 
metastasis disappeared, but new metastases were 
formed more distally along the nail# Since the 
marrow nailing, the patient has walked without 
complaints. In the majority of the cases, however, this spread of 
metastases does not appear, and the 2 mentioned cases are 
exceptions. We now describe the case of R. WANKE, Kiel. 
It was an operated breast carcinoma. The metastasis 
of the bone was localized in a similar way as in the pre- 
ceding case. A spontaneous fracture occurred. Marrow nail- 
ing was performed with subsequent intense radiation. The 
metastasis disappeared. The patient could walk even short- 
ly before her death, which occurred Ij years later on. She 
died of a relapse of her tumor. (See illustration 204)• 
a b 
Illustration 204. 
Metastasis of a breast carcinoma in the area 
of the trochanter. 
a) before marrow nailing 
b) after intense X-ray radiation, 1 year later 
(according to R. WANKE). 
Even in 1940, the author nailed 2 osteoblastic bone 
sarcomae, in which spontaneous fractures had occurred. 
After the marrow nailing, both patients were again able 
to walk, but lived only for 4 and 5 months. Both died 
of pulmonary metastases, but had had pulmonary symptoms 
even at the time of the intervention. In one case, such 
a metastasis could even be proven mth the X-ray (see 
illustration 205). 
The problem is not yet decisively settled whether the 
nail actually causes a more marked spread of metastases. It 
can be judged, only by an extensive statistical study. The 
theoretical idea often does not correspond to practice. This 
is also true for the opinion that the prospect of healing is 
considerably decreased by biopsy excision from a malignant 
tumor. This is well imaginable theoretically, but cannot be 
proven statistically. Thus, a large statistical study of 
W, SIEMENS, Kiel, shows no influence of the biopsy excision 
on the healing prospects of breast carcinoma. a b 
Illustration 205. 
Osteoblastic sarcoma of the femur with 
spontaneous fracture. Thirty-five year 
old female patient M.E. 
a) before marrow nailing 
b) after marrow nailing 
In such desolate oases, this question is of only sub- 
ordinate importance, since it only purports how many weeks 
or months life is shortened by the intervention. The im- 
portant thing is that marrow nailing can render life more 
satisfactory again. 
One must finally admit a certain therapeutic influence 
of the marrow nail on the tumor. The constant small move- 
ments in a spontaneous fracture doubtless have some part 
in the bursting of lymph-paths, tearing of vessels of a 
tumor rich in vessels and the pressing of tumor masses in- 
to clefts of the tissue* We can eliminate these movements, 
not with a plaster cast, but certainly with a marrow nail. 
The general condition is much easier to improve, if the pa- 
tients can get out of bed than if they lie in bed with a 
pelvic plaster cast. Finally, the marrow nail facilitates 
the X-ray radiation. The single radiation is easier sire e 
the patient can be laid in whatever position one chooses, 
and ho may be radiated from more planes than in a plaster 
cast. If the nail is hit by X-rays it emits a strong 
secondary radiation, whichmight bo of therapeutic value. 
In some cases, the tumor in the area of the trochantor 
can be fixed better with a Y-shaped nail than with a straight 
nail (see chapter V). 355 
3* Prophylactic marrow nailing. 
In some 'of the do scribed cases of bone tumors, the spon- 
taneous fracture had not yet occurred, but a marrow nail 
should be inserted,because the fracture was imminent. Such a 
prophylactic marrow nailing saves the patient much pain, dis- 
tress and other disadvantages. In most cases, the tumor is 
recognized previously by drawing pain, etc. Sometimes, it is 
also discovered as an accidental finding during an X-ray ex- 
amination. If the indication of inoperability mentioned with 
the malignant tumor or if the patient refuses amputation, one 
will usually not hesitate to perform the prophylactic marrow 
nailing. In addition, it is technically easier If the spon- 
taneous fracture has not yet appeared* The majority of the 
patients agree at once with the proposal if the consequences 
of further waiting are described to them, A patient of the 
clinics of Kiel refused at first and went home. Eight days 
later, he returned and had the nail inserted. In the mean- 
time he did not get any sleep for fear to awake with a broken 
leg in the morning, which had boon predicted to him as pos- 
sible , 
Such a prophylactic marrow nailing may be finally con- 
sidered also in case of a osteogenesis imperfecta. Frequent 
fractures occur though they all heal rapidly. The final re- 
sult of the numerous fractures, however, are often consider- 
able deformities. In addition, the patients are hospital- 
ized a long time etc. Hero, the nail can prevent further 
fractures. As an example, we mention the 9 year old G.M. who 
had broken the loft femur 7 times, the right femur 6 times, 
and that always subtrochan terically. Illustration 206 shows 
this case after prophylactic marrow nailing. The right nail 
was inserted 2 years ago, the left one year ago. /-iftor mar- 
row nailing, no more fractures occurred (see illustration 206). 
Illustration 206. 
Prophylactic narrow nailing in case of osteo- 
genesis imperfecta of the 9 year old G.M. Be- 
fore the narrow nailing, the right femur had 
been broken 6 times, the left 7 times. The 
right nail was inserted 2 years before, the 
left 1 year. Since then, no more fractures. Considering the rapid growth in childhood, it is im- 
portant to check the position of the nail in the X-ray at 
irt ervals of g year, lest it disappears under the trochan- 
ter tip (see chapter V). Then, it must be replaced in due 
time by a new one. This is a small operation (see chapter 
V). 
fiL. Osteotomy statistics. 
In conclusion of the chapter on osteotomy, we mention 
2 statistical tables, which clearly show what an eminent 
remedy we possess in the marrow nail for the osteosynthesis. 
Not all the advantages of early movability, the anatomical 
final result obtained and the degree of restoration of the 
function are listed therein, but only the question is rough- 
ly answered: Was any success of the osteosynthesis - i.e. 
union by bone - obtained or not? 
The following table was compiled by KOENIG- and WIRTH. 
It was mads from a compilation of 103,314 fractures at 59 
hospitals. 
TABLE OF THE METHODS OF OSTEOSYNTHESIS AND THEIR 
FAILURES, (according to KOENIG and WlRTH). 
Method 
total # 
of cases 
failures 
per- 
centage 
Simple wire suture after operative 
exposure 
38 
12 
31.6 
step-like freshening with wire suture 
45 
4 
8.9 
Kirschner's splintering 
68 
10 
14.4 
simple bone grafts 
214 
40 
18.7 
bone grafts with wire suture 
22 
5 
22.7 
osteoplastic bolting 
autoplastic transplantation of spon- 
38 
5 
13.2 
giosa 
17 
1 
5.9 
autoplastic bone bolting 
30 
7 
23.3 
ivory bolting 
26 
6 
23.1 
LaneTs plate 
In comparison to this, marrow nailing 
14 
• 
• 
3 
21.4 
Osteosynthesis by moans of marrow nails total 
after osteotomy # of 
oases 
failures 
per- 
centage 
\ 
Patients of KUEN'fSCHER 
patients of the clinics in Kiel 
patients of HhEBLEH 
287 2 
not available 
not available 
0,7 
TOTAL; 28? 
2 
0.7 357 
No closed marrow railings are included in order to be 
able to compare them under approximately equal conditions. 
If they were included, the figures would speak even more in 
favor of marrow nailing, since the healing conditions are 
much'better with them. As regards the figures of the au- 
thor, one must consider that numerous serious pseudarthroses 
are included. The absence of a number of failures worth 
mentioning after marrow nailing is eventually also experi- 
mental evidence, as it were, for the correctness of the 
mechanico-biological theories developed in chapter III. 
The failures among the patients of the author are the 
pseudarthroses of the forearm, represented in illustration 
176 and 177, which were healed after a second marrow nail 
osteotomy.