An Innovative, Cost-Effective, and Flexible Traction Alternative for Shoulder Arthroscopy in Lateral Decubitus Position

Abstract

During shoulder arthroscopic surgery in the lateral decubitus position, effective and stable continuous traction is a basic requirement for the smooth progression of the surgery. Herein, we describe a safe, reliable, and cost-effective lateral decubitus traction assembly.

Arthroscopic surgery is now widely used to treat common shoulder disorders, including rotator cuff tears, calcific tendinitis of the shoulder, and recurrent shoulder dislocations.¹ In shoulder surgery, the lateral decubitus position and the beach-chair position are 2 commonly used surgical positions, each with its own advantages.² The choice between these positions depends mainly on the surgeon’s technical skills and preferences. During shoulder arthroscopic surgery in the lateral decubitus position, effective and stable continuous traction is a basic requirement for the smooth progression of the surgery. Such traction is essential not only to help separate the joint cavity and subacromial space but also to ensure proper tension of the soft tissues, which reduces peripheral tissue swelling caused by irrigation fluid.³ Many commercially available arm traction components can be used for shoulder arthroscopy in the lateral decubitus position. However, the costs of these commercially available products can place a heavy financial burden on patients, making them less accessible, especially in developing countries like China, where health care resources are limited. Therefore, by utilizing a regular bandage and a Coban, which are readily available and inexpensive in orthopaedic operating rooms, in combination with an arthroscopic shoulder positioner (ACUFEX-012320, Smith & Nephew), we describe a simple, rapid, and cost-effective arm traction alternative.

Technique

After standard lateral decubitus positioning and prepping/draping, the surgeon uses sterile conventional bandages to prepare to wrap the patient’s forearm. Starting from the distal two-thirds of the forearm, the sterile bandages are wrapped longitudinally along the axis of the arm toward the distal end, passing circumferentially around the fingers and back up the forearm, overlapping in a sugar-tong fashion on the volar and dorsal aspects of the distal two-thirds of the forearm (Fig 1 A and B). The bandages extend 3 to 4 cm distal to the fingers. To ensure adequate final strength, the sterile bandages should be wrapped repeatedly for 5 to 6 layers. The surgeon then lifts the patient’s forearm, with one hand holding the wrist to stabilize the position of the conventional bandages and forearm, forming a ring structure with the bandages distal to the fingers. The other hand grasps the ring formed by the bandages anterior to the patient’s forearm (Fig 1C). The assistant uses a Coban starting at the wrist, wrapping 2 to 3 circles around the wrist to secure the forearm bandages. The assistant then continues wrapping proximally up the forearm until covering all the bandages on both sides of the forearm, with 2 to 3 additional reinforced circles. The Coban is then wrapped distally, passing the wrist and wrapping circumferentially around the hand and fingers. It is important for the assistant to flex the patient’s fingers into a clenched fist when wrapping the hand to ensure the Coban fully envelops the fingers, forming a “bandage ring” distal to the fingers (Fig 1D, Video 1). This ring structure consists of approximately three-fourths conventional sterile bandages and one-fourth the patient’s fingers wrapped by the Coban, with an approximately 3- to 4-cm space between the fingers and bandage. Subsequently, the assistant pulls on the bandage ring to abduct the shoulder joint approximately 45°. Another assistant hooks the bandage ring onto the arthroscopic shoulder positioner and hangs a 10-lb. weight distally for shoulder joint traction (Fig 2A). To avoid potential contamination, the assistant at the bedside changes gloves after completing the hooking maneuver. The connection point between the bandage and traction frame is wrapped with a sterile towel (Fig 2B, Video 1).

Fig 1.

Setup of skin traction (volar view). The patient is positioned in the lateral decubitus position on the operating table, with the surgeon positioned posterior to the patient to perform the procedure. (A) To ensure adequate final strength, the sterile bandages should be wrapped repeatedly for 5 to 6 layers. (B) The sterile bandages are wrapped longitudinally along the axis of the arm toward the distal end, passing circumferentially around the fingers and back up the forearm, overlapping in a sugar-tong fashion on the volar and dorsal aspects of the distal two-thirds of the forearm. (C) The assistant uses a Coban starting at the wrist, wrapping 2 to 3 circles around the wrist to secure the forearm bandages. (D) The assistant flexes the patient’s fingers into a clenched fist when wrapping the hand to ensure the Coban fully envelops the fingers, forming a “bandage ring” distal to the fingers.

Fig 2.

Connection of the traction assembly. (A) The assistant hooks the bandage ring onto the arthroscopic shoulder positioner and hangs a 10-lb. weight distally for shoulder joint traction (volar view). (B) The connection point between the bandage, and traction frame is wrapped with a sterile towel (dorsal view).

The entire procedure takes approximately 3 minutes. The disposable sterile materials used include 1 roll of conventional bandage, 1 roll of Coban, and 1 sterile towel, with a total cost of under US$2. We have utilized this technique for over 3 years, in approximately 300 various types of shoulder arthroscopic surgeries (rotator cuff repair, recurrent shoulder dislocation, debridement, etc.). There have been no complications related to the traction method such as neurovascular symptoms or skin issues (Table 1).

Table 1.

Pearls and Pitfalls of the Modified Traction Technique for Shoulder Arthroscopy in the Lateral Decubitus Position

Pearls

The sterile bandages cover approximately two-thirds of the forearm, avoiding the region of the sulci nervi ulnaris to prevent potential nerve compression.

The elastic bandages should first be wrapped 2 to 3 turns around the wrist joint to form a secure connection between the sterile bandages and the forearm.

When wrapping the elastic bandages around the hand, the fingers should be positioned into a fist to prevent interference with subsequent steps.

Pitfalls

Patients with elbow joint diseases (such as elbow joint flexion contracture) are not suitable for this forearm traction.

The assistant at the bedside should change gloves after completing the hooking maneuver to avoid the potential risk of contamination.

Discussion

For shoulder arthroscopy in the lateral decubitus position, effective, reliable, and flexible lateral traction is one of the key factors in ensuring surgical success. The function of lateral traction is not only for distraction of the joint but also to maintain the position of the upper extremity during surgery and allow adjustments as needed based on surgical requirements.⁴ In order to avoid the medical expenses associated with commercial disposable traction components in developing countries, some attempts have been made using readily available simple materials as substitutes.4, 5, 6 The modified technique we describe in this article is aimed at overcoming the disadvantages of commercial traction components, including the costs of disposable materials and traction devices themselves, which makes them inaccessible and unsuitable for widespread use in low-resource surgical settings. Compared with commercial components and other reported alternative traction methods, our traction technique has the following advantages: first, the sterile materials used in this technique include only sterile bandages and sterile Cobans, which can be found in virtually any basic surgical suite without additional time needed for preparation. The costs are also very low and will not pose a financial burden for patients even in economically underdeveloped regions. Second, compared with alternative methods using tape for forearm fixation, our technique does not have specific requirements for the condition of the patient’s skin surface. It does not require the skin to be completely dry and has minimal risk of skin allergic reactions. Even if the patient has minor abrasions on the forearm skin, traction can still be performed after covering the wounds with dressings. Moreover, since the fixation area is limited to the distal two-thirds of the forearm and does not include the elbow joint, there is minimal risk of nerve injury. Furthermore, our technique allows for flexible adjustment of traction angles during surgery by raising or swinging the traction frame. If there is no dedicated shoulder joint traction frame, a common static frame can also serve the same purpose. The simple equipment requirements also bring another benefit, which is a small space requirement. This is very important for medical institutions that can only provide relatively small operating rooms. Of course, this traction method is not suitable for all patients. Patients with elbow joint diseases (such as elbow joint flexion contracture) are not suitable for using forearm traction or even the lateral decubitus position surgery. Despite its various advantages, our improved traction technique also has its limitations. First, due to the use of bandages instead of tape for wrapping the forearm, this traction method places certain strength requirements: the bandage strength must be able to withstand the traction force, as well as some additional pulling force applied by the surgeon during the operation. Our solution is to ensure that the sterile bandages have 5 to 6 layers to guarantee sufficient strength, while also inspecting the quality of the sterile bandages preoperatively. Practically, we apply this traction method for approximately 6 to 8 shoulder arthroscopic surgeries per week and have not encountered any incidents of bandage breakage. However, this potential risk should be noted. Second, during the preparation of traction, the assistant needs to lift the bandages and install them onto the traction device, which carries a potential risk of contamination. Our solution to this is for the assistant to change into new sterile gloves after completing this action, which ensures sterility but slightly increases the preparation time. Last, since we have used a structurally simpler traction device, assistance from an assistant may be required when adjustments to the shoulder joint position are needed intraoperatively. In practice, the scrub nurse can take on this task (Table 2). But overall, the lateral decubitus position shoulder arthroscopy traction method we introduced, which uses sterile bandages, Cobans, and an arthroscopic shoulder positioner, is safe, reliable, and cost-effective.

Table 2.

Advantages and Disadvantages of the Modified Traction Technique for Shoulder Arthroscopy in the Lateral Decubitus Position

Advantages

Cost-effective and simple equipment and space requirements

No specific requirements for the condition of the patient’s skin surface

Highly adjustable and adaptable

Disadvantages

Potential risk of contamination when improperly handled

Certain requirements for the strength of sterile bandages

Assistant may be required when adjustments to the shoulder joint position are needed intraoperatively

Disclosures

All authors (W.L., A.W., Y.L., Z.Z., F.Z., Y.Z., X.L.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. This research was funded by 2023 Science and Technology Project of Jilin Provincial Department of education, grant number JJKH20231226KJ. Written informed consent has been obtained from the patient to participate in the study and to publish this article, and the patient has consented for all images and clinical data and other data included in the article to be published. The patient also has provided informed consent for the publication of his anonymized case details and images.

Supplementary Data

Video 1

Brief introduction of the modified traction technique. The patient is positioned in the lateral decubitus position on the operating table, with the surgeon positioned posterior to the patient to perform the procedure. Shown are the essential steps: 1. Use conventional bandages to wrap the patient's forearm longitudinally, forming a ring structure extending 3-4 cm beyond the fingertips. 2. The assistant uses a coban bandage starting at the wrist to secure the forearm bandages, then wraps around the fingers forming a “bandage ring.” 3. The assistant pulls on the "bandage ring" to abduct the shoulder joint about 45 degrees, while another assistant hooks the “bandage ring” onto the shoulder traction frame and hangs a 10-lb weight for joint distraction. 4. To avoid contamination, the bedside assistant changes gloves after the hooking maneuver, and the connection point is wrapped in a sterile towel.