Interface pressure produced by the traction post on a standard orthopaedic table

Ipsilateral Foot Drop After Leg Traction on Fracture Table for Mid-Shaft Femur Fracture Nailing: A Rare Case Report

Femoral shaft fracture, one of the most common orthopaedic injuries, is usually treated with intramedullary nailing. During the operative procedure patients are placed on a traction table. Traction tables facilitate the procedure but are associated with some risk. Here we are sharing a case of a 35-year-old male healthy young patient who sustained a foot drop post nailing of femoral shaft fracture on a traction table. This patient has had some recovery in six weeks but is still not fully recovered. We think traction tables are a very helpful tool but carry some risks that should be kept on mind for every surgeon, and for the patients too.

The comparison of the Effect of double reverse traction repositor (DRTR) and traction table assisted Anterograde Intramedullary nail in treatment of femoral shaft fractures

OBJECTIVE

The objective of this study was to compare the clinical efficacy of DRTR (Double Reverse Traction Repositor, DRTR)and traction table in the treatment of femoral shaft fractures with the aid of AN-IMN (Antegrade intramedullary nailing).

PATIENTS AND METHODS

In this study, patients with femoral shaft fractures admitted to the Department of Orthopedics at Zhaoqing First People's Hospital from May 2018 to October 2022 were recruited. All patients were treated with anterograde intramedullary nailing, with 23 patients in the DRTR-assisted group and 21 patients in the traction table-assisted group. The demographic characteristics, fracture classification, intraoperative data, postoperative data, and prognostic indicators of the two groups were recorded and analyzed retrospectively. All procedures were performed by the same team of experienced physicians.

RESULTS

All the patients in the two groups were followed up for more than 12 months. Both traction methods could provide stable traction for the operator during AN-IMN, and there was no significant difference in demographic characteristics and fracture classification. The intraoperative fluoroscopy times and opening reduction rate of the DRTR group were lower than those of the traction table group (P < 0.05), and the postoperative Harris Hip Score, as well as the Lyshol Lysholm knee function Score of the DRTR group, were significantly higher than the traction table group members (P < 0.05). Postoperative complications such as perineal soft tissue injury and lateral femoral cutaneous nerve injury occurred in the traction table group, but not in the DRTR group.

CONCLUSION

DRTR can safely and effectively provide continuous and stable traction in the femoral shaft fractures surgery, and outperforms the traction table in the number of intraoperative fluoroscopy, opening reduction rate, reduction of complications, and postoperative joint function score.

Are complications related to the perineal post on orthopaedic traction tables for surgical fracture fixation more common than we think? A systematic review

BACKGROUND

Traction tables have long been utilized in the management of fractures by orthopaedic surgeons. The purpose of this study was to systematically review the literature to determine the complications inherent to the use of a perineal post when treating femur fractures using a traction table.

METHODS

A systematic review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) using PubMed, EMBASE, and Cochrane Library. The search phrase used was "fracture" AND "perineal" AND "post" AND ("femur" OR "femoral" OR "intertrochanteric" OR "subtrochanteric"). Inclusion criteria for this review were: level of evidence (LOE) of I - IV, studies reporting on patients surgically treated for femur fractures, studies reporting on patients treated on a fracture table with a perineal post, and studies that reported the presence or absence of perineal post-related complications. The rate and duration of pudendal nerve palsy were analyzed.

RESULTS

Ten studies (2 prospective and 8 retrospective studies; 2 LOE III and 8 LOE IV) were included consisting of 351 patients of which 293 (83.5%) were femoral shaft fractures and 58 (16.5%) were hip fractures. Complications associated with pudendal nerve palsies were reported in 8 studies and the mean duration of symptoms ranged between 10 and 639 days. Three studies reported a total of 11 patients (3.0%) with perineal soft tissue injury including 8 patients with scrotal necrosis and 3 patients with vulvar necrosis. All patients that developed perineal skin necrosis healed through secondary intention. No permanent complications relating to pudendal neurapraxia or soft tissue injuries were reported at final follow-up timepoints.

CONCLUSION

The use of a perineal post when treating femur fractures on a fracture table poses risks for pudendal neurapraxia and perineal soft tissue injury. Post padding is mandatory and supplemental padding may also be required. Appropriate perineal skin examination prior to use is also important. Occurring at a higher rate than previously thought, appropriate post-operative examination for any genitoperineal soft tissue complications and sensory disturbances should not be ignored.

Deep neuromuscular paralysis during hip arthroscopic surgery: influence on perineal tissue pressures and hip joint width

Pudendal nerve injuries are not an uncommon side effect of patient positioning on a traction table, and muscle relaxation has been suggested to mitigate this risk by reducing pressure on the perineum. A total of 40 patients scheduled for hip arthroscopic surgery under general anaesthesia were recruited. After induction of anaesthesia, pressures on the perineum were measured in 20 subjects by means of an ultra-thin pressure sensor mat wrapped around the perineal post. Perineal pressures were assessed after the induction of anaesthesia, after leg traction and after deep muscle relaxation. In 22 subjects, the hip joint width was measured radiographically at the same time points. Pressures on the perineum were high after traction (median maximum pressure 2540 g cm⁻²). Neuromuscular paralysis reduced perineal pressures only minimally, but significantly (−5 g cm⁻²; P = 0.007). Traction increased hip joint width significantly [mean 66 (12)%; P = 0.001) and muscle relaxation further increased joint width by a mean of 3.2 (0–20)% (P = 0.001). Muscle relaxation was more beneficial for male patients (joint width increase 6.8% versus 2.8%; P = 0.04), as well as patients in whom traction alone did not achieve sufficient joint width. Muscle relaxation reduced the perineal pressure during hip arthroscopic surgery by only a negligible amount. With regard to joint space, relaxation may be of highest benefit in male patients and/or patients in whom traction alone produces only a relatively small increase in joint width (trial registration: ANZCTR 12617000191392).

The Use of Intraoperative Skeletal Traction for the Repair of Pelvic Fractures: An Experimental Cadaveric Study

OBJECTIVE

 The purpose of this study was to evaluate the use of intraoperative skeletal traction for the surgical repair of pelvic fractures. Opposition and anchorage points for the application of traction were the same in all cadavers.

MATERIALS AND METHODS

 Cadavers from 10 adult dogs with a median body weight of 31.9 kg (range: 20-38 kg) were used. The fractures were experimentally created in all dogs to produce an oblique iliac fracture on the left side and a transverse fracture on the right (total of 20 fractures) at the same time. Dogs were positioned on an operating table in lateral recumbency and traction was applied first on the left side and then on the right after changing the position of the animal. Increasing amounts of traction were applied to each fracture and recorded until a distraction length of 2 cm was created between the bone fragments. The Kolmogorov-Smirnov test confirmed normality of the data, and a paired t-test was used to compare traction of the two fracture types.

RESULTS

 The measurement of traction and distraction of the bone fragments was possible in all fractures. A distraction of at least 2 cm was obtained with a mean peak traction force of 15.4 kg for transverse fractures and 18.6 kg for oblique fractures.

CONCLUSION

 Intraoperative skeletal traction provides a useful and reliable tool for the reduction in experimental oblique and transverse iliac fractures in dogs. There were strong correlations between body weight and the force required to obtain a distraction length of 2 cm in the fracture line; for oblique fractures, traction was related to the square of body weight, and for transverse fractures, the relationship between weight and required traction was near linear.

Percutaneous antegrade nailing with reductor-T tape pin is effective and well tolerated in patients with ipsilateral multisegmental femoral shaft fractures

Objective

This study was performed to investigate the efficacy and safety of percutaneous antegrade nailing with a reductor-T tape pin in the treatment of ipsilateral multisegmental femoral shaft fractures (IMFSFs).

Methods

Nineteen patients with IMFSFs underwent antegrade nailing with a reductor-T tape pin by percutaneous techniques. The operation time, reduction time, fluoroscopy time, blood loss, fracture union time, and complications were recorded.

Results

All 19 patients (100%) achieved technical success. The mean and median operation time were 62.42±16.27 and 60 (range, 40–105) minutes, respectively; the mean and median reduction time were 11.47±3.78 and 10 (range, 8–22) minutes, respectively; the mean and median fluoroscopy time were 16.63±6.10 and 15 (range, 10–35) s, respectively; and the mean and median blood loss were 185.26±62.75 and 180 (range, 110–350) mL, respectively. Additionally, all 19 patients (100%) achieved fracture union within a mean and median time of 3.95±1.75 and 3 (range, 3–9) months, respectively; most patients [n=14 (73.7%)] achieved fracture union within 3 months. No obvious complications occurred during the study.

Conclusion

Antegrade nailing with a reductor-T tape pin by a percutaneous technique is effective and well tolerated in patients with IMFSFs.

Traction table versus double reverse traction repositor in the treatment of femoral shaft fractures

A novel reduction technique of intramedullary nailing (IMN) for femoral shaft fractures was introduced, and in this study, its therapeutic effect was compared with patients treated with the traditional traction table. From November 2012 to August 2015, the patients with femoral shaft fractures fixed with anterograde IMN were reviewed. Seventy-four patients treated with the traction table and forty-eight patients treated with the double reverse traction repositor (DRTR) met the inclusion criteria of this study. The surgical time, blood loss, open reduction rate and complications were reviewed in this study. The fracture healing was assessed by the radiographs conducted at each follow-up. The functional outcome (hip and knee flexion, Harris Hip Score, and Lysholm knee score) was evaluated at the final follow-up. Average surgical time, blood loss, hip and knee flexion, and Harris Hip Score showed no difference (P > 0.05) between the two groups. However, the DRTR was superior to the traction table in fracture healing, Lysholm knee score, open reduction and complications rate (P < 0.05). Thus, we concluded that minimally invasive treatment of femoral shaft fractures could be obtained with the DRTR.

Minimally invasive treatment of displaced femoral shaft fractures with a rapid reductor and intramedullary nail fixation

PURPOSE

Traction table-based intrameduallary (IM) nail fixation is an accepted treatment method for displaced femoral shaft fractures in adults. However, some complications have been described. To avoid complications associated with the use of a traction table, a rapid reductor was invented. This study aims to assess the outcomes of displaced femoral shaft fractures treated by a novel minimally invasive technique that employs a rapid reductor to reduce fracture and facilitate IM nail fixation.

METHODS

Between November 2012 and March 2013, 22 cases of displaced femoral shaft fractures were enrolled into this study. The patients included 13 males and nine females who were between 21 and 42 years old (average, 31.3 years). All the fractures were unilateral and comprised four cases of type 32-A, 13 cases of type 32-B, and five case of type 32-C according to AO/OTA classification of fracture. During the operation, the displaced femoral shaft fractures were firstly reduced by skeletal traction with the use of a rapid reductor, and the residual antero-posterior or lateral displacement were then corrected percutaneously by using a Kirschner wire or Schantz pin with a "joy stick" technique. The fracture reduction was maintained with the rapid reductor and an IM nail was inserted to fix the fracture. The operation time, reduction time, fluoroscopy time, and intra-operative blood loss were recorded. Follow-up was conducted to assess the healing of the fractures and the functional recovery of the injured limbs.

RESULTS

Anatomical or nearly anatomical fracture reduction was achieved in all 22 cases and open reduction was not required in any case. The average operative time, fracture reduction time, fluoroscopy time and blood loss were 58 minutes (range, 43-95 minutes), 9.1 min (range, 6-15 minutes), 13.2 seconds (range, 4.5-41.0 seconds) and 87 mL (range, 60-150 mL), respectively. During the operation, no incident of reductor-induced neurovascular injury or Schantz pin-induced ilium splitting occurred. Twenty-two patients were followed up for an average of 20.3 months (range, 18-22 months). All fractures healed well on an average of six months. No limb length discrepancy was noted.

CONCLUSIONS

The rapid reductor can be applied to effectively achieve and maintain the reduction of displaced femoral shaft fractures in a minimally invasive fashion, which is conducive for IM nailing fixation. The patients exhibited excellent functional recovery.

Pudendal nerve palsy in trauma and elective orthopaedic surgery

The incidence of pudendal nerve palsy following routine trauma and elective orthopaedic surgery procedures ranges from 1.9% to 27.6%. Excessive and/or prolonged traction against the perineal post of a traction table, leading to direct compression and localised ischaemia to the nerve are suggested mechanisms of injury. Misuse of traction and the inappropriate placement of the perineal post, leading to crushing and stretching of the pudendal nerve, are two main contributing factors leading to its postoperative palsy. The sequelae may be sensory, motor or mixed. In most cases, these injuries are transient and tend to resolve within several weeks or months. However, complete neurological recovery may be unpredictable and the effects of ongoing dysfunction potentially disastrous for the individual. In terms of preventative measures, magnitude and duration of traction time should be minimised; traction should be limited to the critical operative steps only. Additionally, the perineal post should be placed between the genitalia and the contralateral leg. A well-padded, large-diameter perineal post should be used (>10cm). Adequate muscle relaxation during anaesthesia is particularly important in young men who have strong muscles and thus require larger traction forces when compared to elderly patients. Orthopaedic surgeons should be aware of the pathophysiology behind the development of this palsy and the measures that can be employed to reduce its occurrence. In procedures where a traction table is employed, consenting for pudendal nerve palsy should be considered by the surgical team.

The optimal skin incision for minimally invasive total hip arthroplasty performed via the anterolateral approach

Twelve total hip arthroplasty procedures were performed in fresh cadaveric specimens via the anterolateral approach using straight 9-cm incisions placed in 2 different locations with respect to anatomical landmarks. During each procedure, the forces applied to the wound edges by each of the hip instruments and the pressures and strains generated along the wound edges were measured. Pressures ranging from 40 to 190 kPa were developed between the retractors and the wound edges during acetabular reaming and femoral rasping. The resulting strain along the wound edges averaged 28% during acetabular reaming and 34% during femoral broaching (P < .0001). Maximum strains were recorded at the ends of each incision and averaged 58% and 61%, respectively (P < .0001). These results were independent of the anatomical placement of the skin incision. In total hip arthroplasty, the mechanical trauma associated with the procedure is primarily determined by the surgical approach to the hip and the properties of the subcutaneous tissues, and not the anatomical location of the skin incision itself.

Traction table-related complications in orthopaedic surgery

Traction tables are used in numerous procedures about the hip and femur, including fracture fixation, hip arthroscopy, and less invasive arthroplasty. The use of a traction table is not without risks, however, and significant complications have been described, including injury to the perineal integument and soft tissues, neurologic impairment, and iatrogenic compartment syndrome of the well leg. The orthopaedic surgeon who uses a traction table for the surgical management of femur fracture must be familiar with the associated potential dangers and risks and must develop a plan to avoid traction table-associated complications, such as use of a radiolucent flat-top operating table for obese patients, adequate patient positioning, and the minimum possible surgical time.

Genitoperineal injuries associated with the use of an orthopedic table with a perineal posttraction

BACKGROUND

Surgical treatment of lower extremity fractures commonly involves the use of orthopedic table with perineal post for countertraction. However, prolonged application of the perineal post has been associated with significant complications. We describe our experience in the management of genitoperineal cutaneous injuries associated with the use of a traction table.

METHODS

Six patients with genitoperineal complications attributed to the use of a traction table were treated at our institution over a period of 2 years. The patient's median age was 25 (range, 20-28) years and all had fractures caused by motor vehicle collision. We evaluated the clinical presentation of these perineal injuries, operative time, therapeutic approach, clinical outcomes, and hospitalization time.

RESULTS

The mean operative time of the orthopedic surgery was 318 minutes +/- 128 minutes (range, 185-540). All patients developed a partial-thickness necrotic area involving the perineum and scrotum in 2 days to 15 days (mean, 7 +/- 5.4) after the surgery. Three patients developed infection of the necrotic tissue. All patients underwent surgical debridement 16.5 days +/- 6.5 days (range, 13-29) after the orthopedic surgery and only one debridement procedure was necessary in all cases. A primary wound closure was possible in one case, and in the other cases the wound healed completely by second intention. The mean hospitalization time was 26.3 days +/- 9.7 days (range, 19-44).

CONCLUSION

Genitoperineal skin necrosis induced by perineal traction posttable is a morbid complication that demands surgical debridement and prolonged hospitalization for your treatment. There are many procedures available to reduce the risk of this complication that should be used more liberally by the orthopedic surgeons.