Cotton‐Swab‐Anchored Suspension Technique for Hands‐Free Lower Extremity Limb Sterilization During Surgical Preparation

Abstract

Manual limb suspension during surgical preparation is labor‐intensive, requires additional personnel, and may increase the risk of musculoskeletal injuries among surgical staff. We describe a cotton‐swab‐anchored suspension technique that uses a sterile bandage (Kerlix) looped around the ankle, secured with 2 cotton swabs inserted into the knot, and suspended from a heavy‐duty intravenous pole. This method enables hands‐free limb elevation, allowing efficient preoperative preparation. After completion of preparation, the limb is released by simply removing the cotton swab. This technique eliminates the need for manual limb holding, reduces occupational strain, provides stable mechanical support, and enables quick, controlled limb release without instruments. It is cost‐effective, reproducible, and suitable for various lower extremity procedures.

Proper positioning and preparation of the surgical site are critical for preventing surgical site infections and ensuring optimal operative conditions. In lower extremity surgery, limb suspension is routinely required to facilitate circumferential prepping and draping. Arthroscopic surgery requires fewer personnel compared with other orthopaedic procedures, and in most cases, no assistant is needed to lift the leg. Conventional methods often rely on manual lifting by surgical assistants, which is inefficient and labor‐intensive and may increase the risk of intraoperative contamination because of personnel movement around the sterile field. ¹ , ² , ³ Furthermore, sustained manual limb holding imposes significant physical strain on surgical staff. ⁴ Studies have shown that the forces required to lift and maintain a lower limb often exceed occupational safety limits, contributing to musculoskeletal injuries—particularly of the back, shoulders, and wrists—among operating room personnel. With the increasing prevalence of obesity and the growing complexity of orthopaedic procedures, there is a pressing need for ergonomic, hands‐free limb suspension systems that improve both efficiency and safety. Existing suspension devices, such as mechanical limb positioners and traction frames, are often expensive, require additional setup time, and may not be readily available in resource‐limited settings. Simple knot‐based suspension techniques using bandages (e.g., the “cow hitch” or “double‐loop” methods) are commonly used but require complex knot tying and instrument‐assisted release, which can be time‐consuming. ⁵ , ⁶ , ⁷

We describe a “cotton‐swab‐anchored suspension” technique that combines a sterile elastic bandage with 2 rigid cotton swabs as a temporary anchor. This system enables hands‐free limb elevation, simplifies the prepping process, and incorporates a quick‐release mechanism that allows safe, 1‐step limb repositioning without the need for additional instruments (Video 1).

VIDEO 1.

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Instructional video showing the cotton‐swab‐anchored suspension technique for hands‐free lower extremity sterilization during surgical preparation. With the patient in the supine position, a sterile bandage is looped around the ankle fixation site and secured using 2 sterile cotton swabs as temporary rigid anchors. The free ends of the bandage are wrapped around a stable mobile intravenous pole to suspend the lower extremity, allowing circumferential disinfection without manual limb holding. After preparation, the limb is manually supported, and the cotton swabs are removed to release the bandage loop in a controlled, instrument‐free manner. Video content can be viewed at https://doi.org/10.1002/atn2.70276.

SURGICAL TECHNIQUE

Step 1: Preparation and Patient Positioning

The procedure begins with the preparation of the required materials, including a commercially available sterile bandage/Kerlix, BA10LS sterile cotton swabs (10 cm, single‐ended; Zhende Medical, China), sterile adhesive tape, povidone‐iodine swabs or solution, a medium‐sized sterile drape, and a SINOCOP mobile intravenous pole (Zhonghe/SINOCOP, China) with adjustable height and a stable weighted base. The pole is positioned adjacent to the operating table. The patient is placed in a supine position to ensure optimal exposure of the surgical site (Figure 1A).

FIGURE 1.

Overall setup and clinical application of the cotton‐swab‐anchored suspension technique for lower extremity preparation. The patient is placed in the supine position with the lower extremity exposed for circumferential skin preparation. (A) A stable mobile intravenous pole is positioned adjacent to the operating table, and a sterile bandage is prepared for ankle suspension. (B) The sterile bandage loop is placed around the ankle fixation site and suspended from the intravenous pole, allowing hands‐free elevation of the lower extremity during preparation. (C) After disinfection, the lower extremity remains suspended, allowing circumferential access to the distal limb while maintaining a controlled and stable position.

Step 2: Bandage Looping and Cotton‐Swab Anchoring

A sterile bandage is folded in half, and the closed end is looped around the patient's ankle, with the midpoint positioned approximately 2 cm distal to the lateral malleolus to maximize anatomical stability. The 2 free ends are brought upward, and 2 sterile cotton swabs are inserted into the loop created at the knot to serve as a rigid anchor (Figure 2). The swabs are pushed downward to secure the knot in place, using the ankle's narrowest anatomical region to prevent slippage. Before suspension, the skin at the ankle fixation site should be inspected carefully. The bandage should be snug but not overly tightened, and the cotton swabs should be positioned to avoid direct excessive focal pressure on thin, fragile, or compromised skin.

FIGURE 2.

Bandage wrapping and cotton swab anchoring process. (A,B) Fold a sterile elastic bandage (Kerlix) in half and wrap the closed end around. (C) Insert 2 cotton swabs into the gap formed by the sterile bandage to provide anchorage.

Step 3: Limb Suspension

The pole is positioned beside the operating table, and the surgeon applies upward traction to elevate the limb to the desired height. The bandage ends are wrapped around the pole 3 to 4 times and secured with sterile tape. This setup enables hands‐free limb positioning and facilitates subsequent preparation and draping (Figure 1B).

Step 4: Surgical Preparation and Quick Release

The surgeon begins disinfecting from the distal end of the limb. Povidone‐iodine swabs are applied to the area where the cotton swabs are inserted, and the fixation bandage is then disinfected upward for at least 10 cm to ensure adequate antiseptic coverage. The bandage wrapped around the limb is also disinfected downward. Subsequently, the remaining areas are disinfected toward the proximal end of the limb (Figure 1C). After completion of preparation, the limb is gently supported by the surgeon, whereas the cotton swabs are withdrawn. The bandage loop then loosens spontaneously, allowing controlled, hands‐free descent of the limb onto the sterile drape. No instruments are required for release (Figure 3). A step‐by‐step summary of this technique is provided in Table 1.

FIGURE 3.

The process of rapid limb release. (A,B) The assistant grasps the tip of the cotton bud and pulls it out to release it quickly. (C) The surgeon catches the limb and moves it onto the operating table.

TABLE 1.

Pearls and Pitfalls of Key Surgical Steps

Key Surgical Step	Pearls	Pitfalls
Bandage looping and knot fixation	Fold the bandage in half; wrap the closed end around the ankle. Use 2 extended‐length cotton swabs (≥10 cm); insert into the knot center and rotate slightly to secure. Maintain the swab parallel to the limb axis to prevent slippage	Overtightening may cause distal ischemia; loose wrapping results in unstable suspension. Standard short cotton swabs may dislodge easily
Suspension setup	Adjust the traction force to match the limb weight. Keep foot 40 to 50 cm away from the bed surface for adequate preparation access	Excessive height of suspended limbs results in instability; insufficient height limits preparation coverage
Preparation	Apply disinfectant to the joint area for enhanced sterility. Disinfect at least 10 cm proximal to the swab fixation site	Excessive disinfectant saturation may compromise knot security
Limb release	Support the limb manually before swab removal to prevent a sudden drop	Rapid or forceful swab removal may cause soft tissue injury

DISCUSSION

We have described a cotton‐swab‐anchored suspension technique that simplifies lower limb positioning during surgical preparation. Compared with traditional manual methods, which require 1 to 2 assistants to maintain limb elevation, our technique enables autonomous, hands‐free suspension, thereby optimizing operating room workflow and reducing personnel requirements. ¹

Existing suspension methods each have distinct limitations. Mechanical limb positioners and traction frames, while effective, are costly, require additional setup time, and may not be available in all surgical settings. Simple knot‐based techniques, such as the “cow hitch” and “double‐loop” methods, are widely used but involve complex knot tying that can be time‐consuming and often require instruments (e.g., hemostats) for release. ⁴ In contrast, our cotton‐swab‐anchored system combines the simplicity of bandage‐based suspension with a simple quick‐release mechanism: the rigid cotton swab serves as both an anchor during prepping and a “key” that, when removed, instantly releases the limb without the need for instruments.

From an ergonomic perspective, this technique addresses the occupational health risks associated with manual limb holding. Studies have shown that the forces required to lift and sustain a lower limb frequently exceed recommended weight limits, contributing to high rates of musculoskeletal injuries among surgical staff. ⁴ , ⁸ By eliminating sustained manual exertion, our technique aligns with modern surgical ergonomics principles and may help reduce occupational injury rates.

Several technical considerations warrant attention. First, appropriate patient selection is important. Because the cotton swab functions as a focal anchoring point rather than a broad‐area manual support, excessive local pressure may theoretically cause skin indentation, superficial abrasion, laceration, or pressure‐related skin breakdown, particularly in patients with thin or tenuous skin. Therefore, this technique should be avoided or used with caution in patients with traumatic knee or ankle dislocations, severe soft‐tissue defects, compromised skin integrity at the fixation site, advanced age with fragile skin, severe edema, peripheral vascular disease, or diabetes‐related skin vulnerability. The fixation site should be inspected before suspension and after release, and the bandage should not be overtightened. If local skin quality is poor, manual support or a broader‐area suspension method should be considered. Second, for patients whose body mass index indicates overweight or obesity, we recommend reinforcing the suspension with an additional bandage loop to improve stability and distribute load. Third, although the technique is simple to learn, we recommend a brief training session for operating room staff to standardize knot placement, swab insertion, traction adjustment, fixation‐site inspection, and controlled limb release. ⁹

In summary, the cotton‐swab‐anchored suspension technique offers a cost‐effective, ergonomic, and reproducible solution for hands‐free limb positioning during surgical preparation. Its quick‐release mechanism and minimal equipment requirements make it particularly suitable for resource‐limited settings and routine clinical practice. The advantages and disadvantages of this technique are outlined in Table 2.

TABLE 2.

Advantages and Disadvantages

Advantages
Eliminates the need for manual limb holding, improving efficiency
Reduces the risk of musculoskeletal injuries among staff
Provides stable support during prepping and draping
Applicable to the suspension of other limbs
Low cost and no special equipment required
The suspension height can be adjusted as required

Disadvantages
Weight capacity limited; not suitable for patients with severe obesity
Potential for focal pressure‐related skin injury at the ankle fixation site, particularly in patients with thin, tenuous, edematous, or otherwise compromised skin

DISCLOSURES

The authors (C.Z., Z.H., L.S., S.Y., Z.D.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.

FUNDING

This work was supported by the Provincial Advantageous Characteristic Discipline of Wenzhou Medical University (Clinical Medicine to Z.D.).