Injury, Int. J. Care Injured (2004) 35, 1214—1215
IDEAS AND INNOVATIONS
A protector for retrograde femoral nailing using proctoscope Banchong Mahaisavariya*, Kongkhet Riansuwan, Panupan Songcharoen Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand Accepted 1 March 2004
KEYWORDS Retrograde femoral nailing; Proctoscope; Patella
Summary An improvised method of using a proctoscope as a protector during the reaming procedure for closed retrograde femoral nailing is described. This protector is easy to handle and can be effectively used to protect the intra-articular structures, patellar cartilage and patellar tendon during the reaming process. The protector can also help minimise the reaming bone dust spilling out into the joint cavity. ß 2004 Elsevier Ltd. All rights reserved.
Introduction
Method
Retrograde femoral nailing is an accepted alternative method for treatment of femoral shaft fractures in the very obese patient and in patients with previous fixation or with a prosthesis in the proximal femur.2,4 Although either an unreamed or a reamed nailing technique can be used, the latter is favoured. Reaming is performed as with antegrade nailing and caution is needed to protect the patella, patellar tendon and proximal tibia from the reamers.3 Most of the instrument sets for closed femoral reaming procedures have a ‘‘flat shield’’ format with a handle or metal tongue to be gripped by hand or held by Kocher’s forceps. These protectors allow limited purchase and are inconvenient for use in retrograde femoral nailing. This paper presents our simple technique to solve the problem.
The metal proctoscope is a simple instrument which is available in most general surgery operating theatres and can be used as a soft-tissue protector. The sleeve is 7 cm long with an outer diameter of 18.0 mm and inner diameter of 17 mm. This will accept a reamer size up to 16.5 mm without jamming. After a 3—4 cm longitudinal incision, with a splitpatellar-tendon or parapatellar approach, the intercondylar notch is perforated by an awl reamer. The metal proctoscope sleeve is then inserted and placed against the intercondylar notch (Fig. 1). The 8 mm T-hand reamers are used to enlarge the femoral canal. The 3 mm reamer guide wire is then inserted into the femoral canal and was passed through the fracture site into the proximal femoral canal. The femoral canal is then gradually enlarged by reaming using the flexible reamer. The femoral canal is gradually reamed up to 1—2 mm larger than the nail to be inserted. The proctoscope is then removed and the nail-driving guide replaced. The nail insertion and distal locking screw insertion are
*Corresponding author. Tel.: þ66-2-4197968; fax: þ66-2-4128172. E-mail address:
[email protected] (B. Mahaisavariya).
0020–1383/$ — see front matter ß 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2004.03.012
A protector for retrograde femoral nailing using proctoscope
Figure 1 The proctoscope is used as a protector during reaming procedure for retrograde femoral nailing.
performed as recommended. Proximal locking screw insertion is performed using a free hand technique.
Discussion Retrograde nails can be inserted with or without reaming of the intramedullary canal. When using a
1215
reamed nailing method, damage to the undersurface of the patella and the proximal tibia may occur during the insertion of these reamers. Another potential problem of intramedullary reaming is reaming debris left in the knee joint. The recommending prevention is to ream through a protective cannula and to thoroughly irrigate the knee after completion of the procedure.3 We have used a proctoscope as a protector for closed antegrade femoral nailing since 1998.1 This method of softtissue protection was later applied for closed retrograde femoral nailing. We found that the method was very helpful and better than any other available protector. The proctoscope not only helped protect the soft tissue and articular cartilage during reaming, it also helped minimise the amount of reaming debris in the knee joint.
References 1. Mahaisavariya B, Songcharoen P, Lamsam C. Soft tissue protector for closed femoral nailing: an alternative of using proctoscope. J Thai Orthop Surg 2002;27:61—2. 2. Moed BR, Watson JT. Retrograde nailing of the femoral shaft. J Am Acad Orthop Surg 1999;7:209—16. 3. Moed BR, Watson JT. Complications of retrograde intramedullary nailing of the femur. Tech Orthop 2001;16:361—71. 4. Ostrum RF. Technique of retrograde femoral nailing of the femur. Tech Orthop 2001;16:354—60.
