Abstract
Effective continuous traction is essential for arthroscopic rotator cuff repair in the lateral decubitus position. However, traditional skin traction devices struggle to maintain consistent local pressure regulation. To address this limitation, we introduce a constant-pressure sleeve equipped with a pneumatic control and feedback system.
Technique Video
Rotator cuff tears are a common shoulder injury, especially in middle-aged and elderly individuals, significantly impacting their quality of life.1 Arthroscopic rotator cuff repair (ARCR) has emerged as a primary treatment owing to its minimally invasive nature and rapid recovery. Patients are typically positioned in 2 ways: the beach-chair position and the lateral position, with each having its own advantages.2,3 The lateral decubitus position is widely used during ARCR because it facilitates joint space visualization, maintains soft-tissue tension, and optimizes surgical outcomes.4 However, during surgery, the traction band on the upper limb may compress the soft tissues, potentially leading to postoperative complications such as numbness and swelling in the limb.5,6 Therefore, effectively managing the traction pressure presents a significant challenge. Some preliminary studies have suggested that appropriate pressure can promote tissue healing, improve local blood circulation, and reduce postoperative edema.7 However, the commonly used skin traction devices, which consist of bandages and sterile drapes, often struggle to provide stable and controllable pressure. These limitations can result in traction injuries, brachial plexus injuries, soft-tissue damage, and persistent pain after surgery.6,8 To address this, we describe a constant-pressure sleeve (CPS) that maintains consistent traction pressure, overcoming the shortcomings of traditional devices, thereby enhancing patient satisfaction and improving clinical outcomes after ARCR surgery.
Surgical Technique
The CPS (Fig 1) is a traction device for upper-limb use during arthroscopic shoulder surgery. It comprises a skin layer, a pressure layer, an inflation tube, an inflation device (automatic pressure regulator), a traction strap, and a gravity traction system. The skin layer and pressure layer are connected, with both layers tightly bonded together. When unfolded, these layers form a rectangular structure reinforced with 3 strong hook-and-loop fasteners (Fig 1 A and B). In use, the skin and pressure layers form a cylindrical structure, with the pressure layer containing a hollow cavity that connects to the inflation device via the inflation tube. The inflation device (automatic pressure regulator) can inflate the hollow cavity, allowing for adjustment of the inflation volume to maintain a constant pressure on the upper limb. The ends of the traction strap are attached to the pressure layer, and the traction strap is positioned on the same side as the inflation tube, connecting to the gravity traction device (Fig 1C). Once the pressure layer is installed on the upper limb, the traction strap and inflation tube will be oriented toward the palm.
Fig 1.
Structure of constant-pressure sleeve (CPS) applied on the patient’s operative side (right upper limb). This clarifies the patient orientation for the surgical setup. (A) The front view of the CPS illustrates its components, which include a skin layer, a pressure layer, an inflating tube, and 3 reinforced hook-and-loop fasteners; these components are arranged in a rectangular shape when normally expanded. (B) The back view of the CPS shows its close contact with the patient’s skin, ensuring effective pressure application. (C) The CPS is a tubular structure when applied, and the inside of the pressurized layer is a hollow cavity. (D) The overhead view of the CPS in use shows that the pressurized layer is connected with the pneumatic equipment through the pneumatic tube, facilitating the inflation process. The patient is placed in the lateral decubitus position.
After the patient is placed under general anesthesia, he or she is positioned in the lateral decubitus position, ensuring that the operative shoulder is facing upward and properly padded to prevent pressure sores. The surgeon begins the procedure by applying skin traction to the affected upper limb by first securing the CPS around the limb and connecting the inflation tube to the automatic pressure regulator (14ATS-III 1018; Medic, Ningbo, China), setting the pressure to 6 kPa (determined through testing as the minimum stable traction pressure). Once the CPS is inflated, an assistant pulls the traction ring to abduct the shoulder joint to about 45°. Another assistant attaches the strap loop to the arthroscopic shoulder locator (AR-1600M; Arthrex, Naples, FL) and suspends a 10-lb weight distally for shoulder joint traction. After the surgical area is disinfected, a sterile towel is used to wrap the affected upper limb and the CPS device. A sterile elastic bandage is applied externally, during which the constant-pressure inflation device adjusts based on the tightness of the bandage, providing a stable pressure of 6 kPa to the upper limb (Fig 2A). To avoid potential contamination, the bedside assistant changes gloves after hooking the traction strap onto the shoulder locator. The connection point between the bandage and traction frame is wrapped with a sterile towel and then secured with a sterile gauze bandage to prevent contamination during the procedure (Fig 2B, Video 1). The application of the CPS takes only a few minutes, does not increase the operation time for the patient, and effectively reduces postoperative complications.
Fig 2.
Connection of traction component with patient placed in lateral decubitus position on the operative (left) side. (A) The assistant hooks the bandage loop to the arthroscopic shoulder locator and suspends a 10-lb weight distally for shoulder traction. The inflation pressure is set to 6 kPa to maintain stable traction. (B) The connection point between the bandage and the traction frame is wrapped in a sterile towel to prevent contamination during the procedure. (CPS, constant-pressure sleeve.)
We found that with the applied pressure, we typically set a standard pressure of 6 kPa, which provides continuous and stable traction. This pressure level effectively maintains traction, ensuring no fluctuations during treatment, thereby helping to achieve the desired therapeutic goals. However, in clinical practice, the pressure value can be appropriately adjusted to accommodate differences in patient body types. Our patients have experienced no traction-related complications, such as neurovascular symptoms or skin issues.
Discussion
Effective continuous traction in the lateral position during ARCR is crucial. The function of lateral traction is not only to separate the joint cavity from the subacromial space but also to maintain the position of the upper limb during the procedure, allowing adjustments based on surgical requirements. The CPS described in this article aims to overcome the shortcomings of commercial traction components.
Our traction technique has several advantages: It achieves a more uniform pressure distribution, effectively reducing local pressure on soft tissues. In addition to traditional cuff traction, similar technologies for traction devices have been described.9,10 For instance, Songur and Sahin9 applied a technique using tape to secure the forearm, connecting it to 3 semicircular lateral straps applied to the dorsal side of the forearm and suspended on a C-arm. Compared with this method, our device does not have specific requirements for the condition of the patient’s skin. It does not necessitate completely dry skin, and the risk of allergic reactions is minimal. Even if there are minor abrasions on the skin of the forearm, traction can still be performed after covering the wounds with dressings. Furthermore, our technique allows for flexible adjustment of the traction angle during the procedure by raising or swinging the traction frame. Without a dedicated shoulder traction frame, a standard intravenous pole and C-arm can serve a similar purpose. Our device is also simple, meaning that it requires minimal space, which is crucial for health care facilities with relatively small operating rooms. Additionally, the CPS is relatively easy to operate and can be flexibly adjusted for cuff pressure according to individual differences, accommodating patients of varying body types. However, this traction method may not be suitable for all patients. Those with elbow joint conditions (e.g., elbow flexion contracture) are not appropriate candidates for forearm traction or even lateral-position surgery.
Despite its various advantages, our improved method also has limitations. First, the use of the CPS requires adaptation by and training of both the surgeon and the assisting team. Initial use may lead to surgical interruptions or decreased efficiency owing to unskilled operation or poor coordination. Second, the CPS may have higher costs compared with traditional traction devices, making it less accessible for widespread use in resource-limited surgical environments, and it may not be suitable for emergency situations. Finally, assistance may be required to adjust the shoulder joint position during the procedure (Table 1). The limitations of the application of the CPS indicate that further clinical trials and technical optimizations are needed to assess this device’s applicability for different surgical techniques and complex cases.
Table 1.
Key Points and Pitfalls
| Description | Explanation |
|---|---|
| Key points | |
| Stable and evenly distributed pressure | The constant-pressure sleeve provides stable and evenly distributed traction pressure, reducing the risk of localized edema. |
| Alleviation of postoperative complications | The technique helps alleviate common postoperative complications (e.g., pain and numbness), improving early patient satisfaction. |
| No specific requirements for skin condition | The technique can be applied without specific prerequisites regarding the condition of the patient’s skin. |
| Simple operation with strong adaptability | The sleeve is designed for ease of use, allowing for quick application and adaptability to various surgical scenarios. |
| Minimal equipment and space requirements | Minimal equipment and space are required for this technique, making it practical for operating rooms with limited resources. |
| Pitfalls | |
| Need for assistance in position adjustment | Adjusting the shoulder joint position intraoperatively may require assistance from the surgical team. |
| Cost considerations | Cost may be higher than that of traditional traction sleeves, which can be a consideration for budget-constrained facilities. |
| Limitations for patients with elbow joint conditions | The technique is not suitable for patients with existing elbow joint conditions (e.g., elbow flexion contracture). |
Although the CPS has been effective in most patients, variations in body type, skin condition, and preoperative physical characteristics prior to surgery may lead to differing pressure requirements. For some patients with smaller body types or skin sensitivity issues, excessive pressure may not be tolerated while insufficient pressure may fail to achieve therapeutic effects. Therefore, although we recommend 6 kPa as the standard pressure value, adjustments may be necessary for certain patients, requiring the surgeon and assisting team to exercise flexibility in clinical practice. Future research could focus on pressure selection for different patients and long-term follow-up, comparing postoperative functional recovery and complication rates to comprehensively evaluate the actual clinical benefits of the CPS. Overall, we present a safe, reliable, and cost-effective method for shoulder arthroscopy traction using the CPS and inflation device in the lateral decubitus position.
Disclosures
All authors (W-j.G., H-t.J., R-t.Z.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
Correct application of the constant-pressure traction sleeve (CPS) on the patient's operative (right) upper limb is shown after rotator cuff repair. The key steps consist of installing the constant-pressure sleeve (CPS) on the affected limb (at 5 seconds) and inflating the sleeve to maintain a constant pressure of 6 kPa (at 40 seconds). The patient is placed in the lateral decubitus position with the operative right shoulder facing upward. The instruments consist of the CPS, an automatic pressure regulator (Medic), and an arthroscopic shoulder locator (AR-1600M; Arthrex). The video highlights the key steps of applying the CPS, including limb preparation, the inflation procedure, and the proper positioning of the traction system while emphasizing the maintenance of sterile conditions to avoid contamination.
References
- 1.Yamamoto A., Takagishi K., Osawa T., et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. 2010;19:116–120. doi: 10.1016/j.jse.2009.04.006. [DOI] [PubMed] [Google Scholar]
- 2.Frank R.M., Saccomanno M.F., McDonald L.S., Moric M., Romeo A.A., Provencher M.T. Outcomes of arthroscopic anterior shoulder instability in the beach chair versus lateral decubitus position: A systematic review and meta-regression analysis. Arthroscopy. 2014;30:1349–1365. doi: 10.1016/j.arthro.2014.05.008. [DOI] [PubMed] [Google Scholar]
- 3.Peruto C.M., Ciccotti M.G., Cohen S.B. Shoulder arthroscopy positioning: Lateral decubitus versus beach chair. Arthroscopy. 2009;25:891–896. doi: 10.1016/j.arthro.2008.10.003. [DOI] [PubMed] [Google Scholar]
- 4.Hennrikus W.L., Mapes R.C., Bratton M.W., Lapoint J.M. Lateral traction during shoulder arthroscopy: Its effect on tissue perfusion measured by pulse oximetry. Am J Sports Med. 1995;23:444–446. doi: 10.1177/036354659502300412. [DOI] [PubMed] [Google Scholar]
- 5.Baron J.E., Duchman K.R., Hettrich C.M., et al. Beach chair versus lateral decubitus position: Differences in suture anchor position and number during arthroscopic anterior shoulder stabilization. Am J Sports Med. 2021;49:2020–2026. doi: 10.1177/03635465211013709. [DOI] [PubMed] [Google Scholar]
- 6.Li X., Eichinger J.K., Hartshorn T., Zhou H., Matzkin E.G., Warner J.P. A comparison of the lateral decubitus and beach-chair positions for shoulder surgery: Advantages and complications. J Am Acad Orthop Surg. 2015;23:18–28. doi: 10.5435/JAAOS-23-01-18. [DOI] [PubMed] [Google Scholar]
- 7.Dong Z., Li Y., Xue H., Tao L., Tian H. Tourniquet effect on patients undergoing total knee arthroplasty: A single-blind, randomized controlled trial. Orthop Surg. 2024;16:2714–2721. doi: 10.1111/os.14184. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Paul R.W., Zareef U., Streicher S., et al. Beach-chair versus lateral decubitus positioning for arthroscopic posterior shoulder labral repair: A retrospective comparison of clinical and patient-reported outcomes. Am J Sports Med. 2022;50:2211–2218. doi: 10.1177/03635465221095243. [DOI] [PubMed] [Google Scholar]
- 9.Songur M., Sahin E. A simple traction assembly for shoulder arthroscopy in lateral decubitus position: A cost-effective alternative. Arthrosc Tech. 2015;4:e341–e343. doi: 10.1016/j.eats.2015.03.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Luo W., Wang A., Li Y., et al. An innovative, cost-effective, and flexible traction alternative for shoulder arthroscopy in lateral decubitus position. Arthrosc Tech. 2024;13 doi: 10.1016/j.eats.2024.103088. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Correct application of the constant-pressure traction sleeve (CPS) on the patient's operative (right) upper limb is shown after rotator cuff repair. The key steps consist of installing the constant-pressure sleeve (CPS) on the affected limb (at 5 seconds) and inflating the sleeve to maintain a constant pressure of 6 kPa (at 40 seconds). The patient is placed in the lateral decubitus position with the operative right shoulder facing upward. The instruments consist of the CPS, an automatic pressure regulator (Medic), and an arthroscopic shoulder locator (AR-1600M; Arthrex). The video highlights the key steps of applying the CPS, including limb preparation, the inflation procedure, and the proper positioning of the traction system while emphasizing the maintenance of sterile conditions to avoid contamination.