A Simple Traction Assembly for Shoulder Arthroscopy in Lateral Decubitus Position: A Cost-Effective Alternative

Abstract

The lateral decubitus position shoulder arthroscopy requires traction for positioning, as well as distraction. We describe a cost-effective lateral decubitus traction assembly for shoulder arthroscopy.

Shoulder arthroscopy has become a common procedure for various traumatic or degenerative shoulder problems in adults, including elderly persons. It is commonly performed with patients in 2 positions: lateral decubitus and beach chair. Although both positions have certain advantages over each other, no clear superiority could be shown for either method.¹ The choice depends mainly on surgeon preference. Continuous traction is essential during lateral decubitus shoulder arthroscopy. Traction not only helps with distraction of the joint and subacromial space but also keeps tension on the soft tissues, thus minimizing swelling caused by irrigation fluid. There are commercially available shoulder positioning systems (e.g., 3-Point Shoulder Distraction System [Arthrex, Naples, FL] or Spider 2 [Smith & Nephew, Andover, MA])2, 3 for lateral decubitus positioning that hold instruments attached to the operating table. These systems use sterile or non-sterile disposable sleeves for grasping of the extremity, causing an increase in the cost of the operation. We present an inexpensive, readily available, practical lateral traction method.

Technique

After routine lateral decubitus positioning, the surgeon applies skin traction with ordinary adhesive cloth (not silk) plaster tape (Roll-Plast [zinc oxide and rubber–based adhesive cloth plaster tape measuring 5 cm × 5 m]; Kurtsan Medikal, Istanbul, Turkey). It is extremely important for the skin to be free of any ointment or greasy material and to be completely dry and healthy without blisters or lesions. The surgeon starts applying tape to the ulnar side of the forearm from the elbow, continuing distally. A loop is made after passing along the ulnar side of the hand. The surgeon continues proximally on the radial aspect of the hand and forearm and ends tape application at the elbow; this results in application in a sugar-tong fashion. Taping is repeated to produce a 2-layer strap. The surgeon connects the tapes with 3 semicircular transverse bands applied to the dorsal aspect of the forearm (Fig 1). Care is taken to leave the volar forearm untaped to avoid circulatory impairment. Then, a rope or bandage is attached to the loop of the skin traction construct. The C-arm apparatus is positioned at the end of the table, vertical to the long axis of the table, secured by settling the brakes of the device. The rope is passed over the upper arm of the C-arm apparatus. Three to six kilograms of weight is attached to the free end of the rope overhanging the C-arm. Traction weights must be attached gradually to avoid traction injury. Pearls and pitfalls of the technique are summarized in Table 1. By using motorized adjustment of the C-arm and operating table, an abduction range of 20° to 40° can be achieved. In addition, a range from 20° of flexion to 20° of extension can be achieved by back-and-forth mobilization of the C-arm unit. After skin preparation, the skin traction construct and rope are wrapped with a multilayer sterile towel. The towel is secured by wrapping it with a couple of sterile gauze bandages measuring 15 cm × 1.5 m (Roll-Flex [cotton hydrophilic gauze bandage measuring 75 cm × 1.5 m, sterilized with ethylene oxide]; Kurtsan Medikal) to avoid contamination during the procedure (Fig 2, Video 1). It takes not more than a few minutes to apply this construct. Overall, the disposable material used in this method is 1 roll of ordinary adhesive plaster tape measuring 5 cm × 5 m and 2 rolls of sterile gauze bandage measuring 15 cm × 1.5 m, adding up to a cost of less than $2.

Fig 1.

Skin traction applied: (A) dorsal view and (B) volar view.

Table 1.

Key Points and Pitfalls

Key points

The C-arm device must be secured firmly at the end of the table.

The skin must be dry and free of ointment.

Pitfalls

Semicircular tape should engage both arms of traction tape; the volar side must remain untaped.

Traction weights must be applied gradually to avoid traction injury.

Fig 2.

The skin traction construct is attached to a rope. The rope is passed over the upper arm of the C-arm apparatus. The traction construct is wrapped by a sterile towel secured with sterile gauze bandages to avoid contamination.

We have been using the described method for more than 2 years. In this period, we have performed more than 100 shoulder arthroscopy procedures (cuff repair, instability repair, subacromial decompression, and debridement). Among these patients, there have been no cases of traction-related complications such as neuropathy, vascular impairment, or skin problems.

Discussion

Lateral traction for shoulder arthroscopy in the lateral decubitus position is needed not only for distraction of the joint but also for positioning of the whole extremity throughout the procedure. Other than disposable and commercially available traction positioning systems, similar techniques using different grasping tools have been described. Ahmad et al.⁴ used a wrist splint with a metal carabina (split ring) for grasping of the upper extremity. Disbursement of disposable materials in orthopaedic surgical practice is a common problem in developing countries. We described our technique to overcome disbursement problems regarding disposable sterile upper extremity–grasping apparatuses and expensive positioning devices, thus minimizing the costs of the treatment. The main advantage of this technique is the cost and ease of application. The C-arm apparatus, sterile gauze bandage, and adhesive plaster tape are available in almost any surgical theater. Modification of the amount and direction of distraction can be achieved easily. Because the whole extremity is elevated, soaking of the towel and bandages wrapping the traction construct by irrigation fluid is not a concern. There are also drawbacks of this method. The main problem encountered is conversion to an open procedure in occasional cases, which is a common problem when using the lateral decubitus position that is unrelated to the traction apparatus. In addition, this method enables abduction-adduction and flexion-extension to a certain point. Rotations and further abduction, flexion, or extension necessitate an assistant's help. Finally, patients with elbow pathologies (e.g., contracture) are not good candidates for this technique. Skin traction with adhesive tapes, as well as C-arm apparatus–assisted positioning and traction, is a safe and cost-effective method for lateral decubitus shoulder arthroscopy.

Supplementary Data

Video 1

Application of traction.