Hemilithotomy Position Research Articles

The Effect of Intraoperative Patient Positioning on the Success of Intertrochanteric Fracture Surgery in Older Patients.

Background and Objectives: The incidence of hip fractures in people of advanced ages is increasing due to our aging society. Patient positioning for the intertrochanteric fractures of the femur can be performed in various ways. The aim of this study is to clinically and radiologically compare the use of the supine hemilithotomy position, the lateral decubitus position, and the traction table when performing proximal femoral nail (PFN) surgery for femoral intertrochanteric fractures in the geriatric age group. Materials and Methods: A total of 170 elderly patients with femoral intertrochanteric fractures were included in this cross-sectional study. The patients were divided into three groups (the supine hemilithotomy group, the lateral decubitus group, and the fracture table group). For the postoperative period, complications, length of stay in the intensive care unit, and length of stay in hospital were examined, while in postoperative radiographs, tip-apex distances (TADs), collodiaphyseal angles (CDAs), and Cleveland-Bosworth quadrants were examined to evaluate the placement of the lag screw in the femoral head. The quality of fracture reduction was evaluated according to the modified Baumgaertner criteria. Results: The mean age of the patients was 77.8 ± 8.8; 57.6% of patients were female. According to the modified Baumgaertner criteria, it was determined that patients with 'poor' reduction quality had an approximately ten times higher risk of cut-out than those with 'good' reduction quality (OR = 10.111, p = 0.002, 95% confidence interval; 2.313-44.207). The operative time for patients in the fracture table group was longer than that of the other groups Additionally, the CDA in the supine hemilithotomy position group was longer. Conclusions: Although PFN surgery using the traction table is longer in terms of surgical time compared to surgery performed in the lateral decubitus position and the supine hemilitotomy position, it is advantageous in terms of better TAD and CDA values and lower complication rates.

Well Leg Compartment Syndrome: Pathophysiology, Prevention, and Treatment.

The development of compartment syndrome involving the lower limb is a potentially devastating complication of prolonged surgery in patients held in the lithotomy position. Well leg compartment syndrome (WLCS) was recognized in 1953. The incidence of this condition has been reported to range from 0.20% to 0.03%. The mechanism of WLCS development in the absence of trauma appears to be related to prolonged hypoperfusion of the limb, pressure on the muscle compartments, and in some cases, reperfusion of the ischemic limb. This grave complication develops either during or immediately after prolonged surgery in which the patient was held in the Lloyd-Davies lithotomy or hemi-lithotomy position. Surgeons must be aware of the potential for WLCS development during prolonged surgery. Signs of developing WLCS include swelling, increased firmness of the muscle compartments, discoloration, and cooling of the limb. Preventive measures can be taken without contaminating the surgical field by returning the limb to the right atrium level. Once the diagnosis has been made, failure to prevent the development of WLCS requires extensile fasciotomy of each leg compartment to restore perfusion and relieve elevated intra-compartment pressures. This article reviews the pathophysiology, prevention, and treatment of WLCS.

Scissor Position of the Orthopedic Table for the Resolution of Intertrochanteric and Subtrochanteric Hip Fractures

During the surgical resolution of intertrochanteric and subtrochanteric hip fractures on an orthopedic table, a fluoroscope needs to be used in orthogonal planes. This requires that the contralateral leg does not obstruct the radioscopic view, so patients are often placed in a hemilithotomy position. This position, also called the Lloyd-Davis position, involves hip flexion, hip abduction, hip external rotation, and knee flexion. However, rare complications, such as acute leg posterior compartment syndrome, have been described.In addition, patients with severe osteoarthritis and joint stiffness or a history of total hip arthroplasty may have difficulty achieving this position, and the well leg may be at risk of injury in a hemilithotomy position. A previously described position called the “scissor position” is, in our opinion, a safer and more efficient technique for placing the well leg on the orthopedic table, using only a pillow and a self-adhesive compression bandage. This simple position allows a lateral fluoroscopic view of the injured femur without overlapping or interference from the other limb.

Well leg compartment syndrome in trauma surgery - femoral shaft fracture treated by femoral intramedullary nailing in the hemilithotomy position: case series and review of the literature.

Well leg compartment syndrome (WLCS) is a rare complication which can occur following urological, gynecological, general surgical or orthopedic surgeries carried out with the lower limb in the hemilithotomy position. WLCS is associated with significant morbidity and mortality because delay in diagnosis and treatment can lead to loss of function and even life-threatening complications. During orthopedic surgeries on a traction table, such as femoral nailing, the contralateral “well leg” is often placed in the hemilithotomy position, thus facilitating the use of fluoroscopy. This position (also named the Lloyd-Davis position) consists of hip flexion, abduction, external rotation and knee flexion. We present the cases of two teenaged patients who underwent femoral nailing on an extension table of a femoral fracture and developed WLCS. We also present a review of the literature and a discussion of the pathophysiology, risk factors and treatment of this condition. Clinicians need to be aware of the risk factors for WLCS and have high index of suspicion. Further studies looking at the risks, benefits and feasibility of ways to reduce this risk are required.

Delayed lower leg compartment syndrome in the uninjured limb following hemilithotomy positioning: Report of three cases, review of the literature, and recommendations for prevention

Compartment syndrome in the uninjured leg as a complication of prolonged positioning in a hemilithotomy position is a serious complication. Prolonged operative time, external compression, and elevation of the sound leg are contributing factors. This is a devastating, but rare complication in the uninjured leg

Proper Patient Positioning and Complication Prevention in Orthopaedic Surgery.

➤ The consequences of improper intraoperative positioning can be profound: it not only may cause substantial morbidity but also may be a major area of litigation, particularly when peripheral nerve injury occurs.➤ The ulnar nerve is most likely to be injured secondary to improper positioning. The elbow should be flexed ≤90° and the forearm placed in a neutral or slightly supinated position intraoperatively to minimize pressure in the cubital tunnel.➤ Pressure-related complications, such as pressure ulcers and alopecia, are best avoided by the use of adequate padding. Cushions on the operating-room table and armrest should be emphasized under osseous prominences.➤ Positioning the head in a non-neutral alignment or arm abduction of ≥90° may result in injury to the brachial plexus.➤ The hemilithotomy position increases intracompartmental pressure in the leg on the uninjured side. The risk of well-leg compartment syndrome can be minimized by avoiding this position if possible.

REMOVED: Retraction notice to The Use of a Femoral Distractor to Aid Distal Tibial Resection During Total Ankle Arthroplasty

1. Meyer RS, White KK, Smith JM, Groppo ER, Mubarak SJ, Hargens AR. Intramuscular and blood pressures in legs positioned in the hemilithotomy position. J Bone Joint Surg (Am) 84-A 10:1829–1835, 2002. 2. Weber O, Kabir K, Goost H, Wirtz DC, Burger C. The ‘‘well-leg’’ syndrome: calf compartment after lithotomy position. Z Orthop Unfall 146(2):261–263, 2008. 3. Kumamoto T, Hara S, Yoshitake A, Shimoda O, Terasaki H. Well leg compartment syndrome during prolonged surgery in the lithotomy position. Masui 56(6):695– 698, 2007.

The Extended Knee Hemilithotomy Position for Gastrocnemius Recession

The focus of this communication is to share an alternative positioning method that we have used over the past 3 years for gastrocnemius recession with the patient supine on the operating table. The technique uses a candy-cane leg holding system to situate the patient in the extended knee hemilithotomy position. We have found that this position provides excellent visualization of the surgical site, furnishes the anesthesiologist with optimal access to the patient, negates the need to turn the patient from prone to supine when adjunct procedures are to be undertaken, and allows the involved extremity to remain sterile throughout the operation, without an increase in complications or cost.

INTRAMUSCULAR AND BLOOD PRESSURES IN LEGS POSITIONED IN THE HEMILITHOTOMY POSITION

Acute compartment syndrome has been widely reported in legs positioned in the lithotomy position for prolonged general surgical, urologic, and gynecologic procedures. The orthopaedic literature also contains reports of this complication in legs positioned on a fracture table in the hemilithotomy position. The purpose of this study was to identify the risk factors for development of acute compartment syndrome resulting from this type of leg positioning. Eight healthy volunteers were positioned on a fracture table. Intramuscular pressures were continuously measured with a slit catheter in all four compartments of the left leg with the subject supine, in the hemilithotomy position with the calf supported, and in the hemilithotomy position with the heel supported but the calf free. Blood pressure was measured intermittently with use of automated pressure cuffs. Changing from the supine to the calf-supported position significantly increased the intramuscular pressure in the anterior compartment (from 11.6 to 19.4 mm Hg) and in the lateral compartment (from 13.0 to 25.8 mm Hg). Changing from the calf-supported to the heel-supported position significantly decreased intramuscular pressure in the anterior, lateral, and posterior compartments (to 2.8, 3.4, and 1.9 mm Hg, respectively). The mean diastolic blood pressure in the ankle averaged 63.9 mm Hg in the supine position, which significantly decreased to 34.6 mm Hg in the calf-supported position. Changing to the heel-supported position had no significant effect on the diastolic blood pressure in the ankle (mean, 32.8 mm Hg). The mean difference between intramuscular pressure and diastolic blood pressure in the supine position was approximately 50 mm Hg in each of the four compartments. This mean difference significantly decreased to <20 mm Hg in the calf-supported position and then, when the leg was moved into the heel-supported position, significantly increased to approximately 30 mm Hg in all compartments. The combination of increased intramuscular pressure due to external compression from the calf support and decreased perfusion pressure due to the elevated position causes a significant decrease in the difference between the diastolic blood pressure and the intramuscular pressure when the leg is placed in the hemilithotomy position in a well-leg holder on a fracture table. Combined with a prolonged surgical time, this position may cause an acute compartment syndrome of the well leg. Leaving the calf free, instead of using a standard well-leg holder, increases the difference between the diastolic blood pressure and the intramuscular pressure and may decrease the risk of acute compartment syndrome.

Compartment Syndrome of the Leg After Less Than 4 Hours of Elevation on a Fracture Table

Compartment syndrome of the leg is usually associated with significant trauma. It has also been associated with prolonged surgery in the hemilithotomy position. Fracture tables that are used for the internal fixation of proximal femur fractures under fluoroscopy place a patient in this position. This report chronicles two cases of intraoperative compartment syndrome of the leg that was elevated and contralateral to a subtrochanteric femoral fracture. In each case, the syndrome was found at the procedure's conclusion and was addressed with fasciotomies. One patient continued to have neurologic sequelae from the compartment syndrome 2 years later.

Compartment Syndrome of the Leg After Less Than 4 Hours of Elevation on a Fracture Table

Compartment syndrome of the leg is usually associated with significant trauma. It has also been associated with prolonged surgery in the hemilithotomy position. Fracture tables that are used for the internal fixation of proximal femur fractures under fluoroscopy place a patient in this position. This report chronicles two cases of intraoperative compartment syndrome of the leg that was elevated and contralateral to a subtrochanteric femoral fracture. In each case, the syndrome was found at the procedure's conclusion and was addressed with fasciotomies. One patient continued to have neurologic sequelae from the compartment syndrome 2 years later.

Compartment Syndrome in the Well Leg: A Complication of the Hemilithotomy Position

Adler, Louis M. M.D; Heppenstall, R B M.D; Esterhai, John L. Jr. M.D Author Information

Compartment Syndrome in the Well Leg Resulting From Fracture-Table Positioning

A variety of patient positioning options exist on modern fracture tables for use during intramedullary nailing procedures. With the advent of interlocking and reconstruction nailing, some of these procedures can be complicated and prolonged. The use of the hemilithotomy position for prolonged intramedullary nailing procedures can result in the development of a compartment syndrome in the uninjured leg, no matter what type of suspension device is used for that leg. The occurrence of this iatrogenic injury in the patient's well leg can be devastating in light of the contralateral fracture. Two patients at this institution have had such a condition in the past two years, and the authors have revised their positioning procedures. Review of the surgical literature shows that this complication has been seen in urologic, gynecologic, and general surgical patients, but has not been widely reported in the orthopaedic population. Recommendations for avoiding this problem include the use of other positions or distraction devices when performing intramedullary nailings, or, when the hemilithotomy position cannot be avoided, early intraoperative repositioning of the leg when possible.

Compartment syndrome complicating use of the hemi-lithotomy position during femoral nailing. A report of two cases.

Locked intramedullary nailing for the treatment of comminuted femoral fractures is highly effective. However, there may be complications that result in an unsatisfactory clinical outcome. We present the cases of two patients who had compartment syndrome in the calf after use of the hemilithotomy position during closed locked nailing of the contralateral femur