Intramedullary nailing biomechanics: Evolution and challenges

This article aims to review the biomechanical evolution of intramedullary nailing and describe the breakthrough concepts which allowed for nail improvement and its current success. The understanding of this field establishes an adequate background for forthcoming research and allows to infer on the path for future developments on intramedullary nailing. It was not until the 1940s, with the revolutionary Küntscher intramedullary nailing design, that this method was recognized as a widespread medical procedure. Such achievement was established based on the foundations created from intuition-based experiments and the first biomechanical ideologies. The nail evolved from allowing alignment and stability through press-fit fixation with nail-cortical wall friction to the nowadays nail stability achieved through interlocking screws mechanical linkage between nail and bone. Important landmarks during nail evolution comprise the introduction of flexible reaming, the progress from slotted to non-slotted nails design, the introduction of nail ‘dynamization’ and the use of titanium alloys as a new nail material. Current biomechanical improvement efforts aim to enhance the bone–intramedullary nail system stability. We suggested that benefit would be attained from a better understanding of the ideal mechano-biological environment at the fracture site, and future improvements will emerge from combining mechanics and biological tools.