Intraoperative Skeletal Traction Research Articles

The use of skin traction as an intraoperative adjunct for correction during pediatric neuromuscular scoliosis correction.

Intraoperative traction can improve deformity correction during posterior spinal fusion (PSF). This is commonly done with invasive distal femoral or pelvic pins, or traction boots. The novel technique of intraoperative skin traction (ISkinT) avoids risks associated with intraoperative skeletal traction (ISkelT) or hyperlordosis with extended hip position. We aimed to describe ISkinT and assess its safety and efficacy in PSF in non-ambulatory scoliosis. Retrospective review of patients aged 10-21yo who underwent T2-pelvis PSF with ISkinT from 2017 to 2023. Demographics and radiographic measurements were statistically compared to a published cohort that used ISkelT. 42 patients treated with ISkinT were included and compared to 41 patients treated with ISkelT. ISkinT was applied by a cranial attachment and an average of 12% body weight to the pelvis with the hips and knees flexed, using tape-rope-weight system with Trendelenburg assistance. The preop major Cobb was 90°±21° in the ISkinT cohort and 91°±17° in the ISkelT cohort (p = 0.743; d = 0.07), which corrected 75% in ISkinT and 53% in ISkelT (p < 0.0001; d = 1.3). Preop pelvic obliquity averaged 23°± 10° in ISkinT and 34°±14° in ISkelT that corrected 74% in ISkinT and 65% in ISkelT (p < 0.0001; d = 0.95). No intraop or postoperative skin traction-related complications occurred, including neuromonitoring complications (obtained in 88%). In non-ambulatory neuromuscular pediatric scoliosis patients, ISkinT during PSF to the pelvis is a safe and effective technique for deformity correction. There were no associated complications and no difference of corrective capacity for ISkinT compared to ISkelT. ISkinT can be considered for T2-pelvis PSF for pediatric scoliosis.

Head Fixation in Head Frame in Surgeries of Unstable Craniovertebral Junction through Midline Posterior Approach

Abstract Intraoperative skeletal traction with Gardner-Wells tongs or Crutchfield tongs is often used during surgery for craniovertebral junction (CVJ) instability. During these posterior surgical procedures for CVJ instability, there is pressure on occiput/C1 while subperiosteal dissection, drilling, and insertion of screws. With cervical traction, there is a possibility of anterior movement of occiput/C1 due to pressure while performing the above steps. This may lead to undesirable compression of the cervicomedullary junction. The use of rigid head fixation during CVJ surgeries will prevent any such unwanted anterior movement of occiput/C1. Furthermore, the use of the reverse Trendelenburg position allows the body weight to provide counter traction while the rigid frame provides traction allowing reduction of atlantoaxial dislocation. Authors conclude that head fixation in the frame is safer than skeletal traction for CVJ surgeries, through midline posterior approach, for traumatic or congenital anomalies related instabilities.

The Use of Intraoperative Skeletal Traction for the Repair of Pelvic Fractures: An Experimental Cadaveric Study.

The purpose of this study was to evaluate the use of intraoperative skeletal traction for the surgical repair of pelvic fractures. Opposition and anchorage points for the application of traction were the same in all cadavers. Cadavers from 10 adult dogs with a median body weight of 31.9 kg (range: 20-38 kg) were used. The fractures were experimentally created in all dogs to produce an oblique iliac fracture on the left side and a transverse fracture on the right (total of 20 fractures) at the same time. Dogs were positioned on an operating table in lateral recumbency and traction was applied first on the left side and then on the right after changing the position of the animal. Increasing amounts of traction were applied to each fracture and recorded until a distraction length of 2 cm was created between the bone fragments. The Kolmogorov-Smirnov test confirmed normality of the data, and a paired t-test was used to compare traction of the two fracture types. The measurement of traction and distraction of the bone fragments was possible in all fractures. A distraction of at least 2 cm was obtained with a mean peak traction force of 15.4 kg for transverse fractures and 18.6 kg for oblique fractures. Intraoperative skeletal traction provides a useful and reliable tool for the reduction in experimental oblique and transverse iliac fractures in dogs. There were strong correlations between body weight and the force required to obtain a distraction length of 2 cm in the fracture line; for oblique fractures, traction was related to the square of body weight, and for transverse fractures, the relationship between weight and required traction was near linear.

The Use of an Intraoperative Skeletal Traction Device for Delayed Reduction in Pelvic Fractures in Two Dogs

AbstractTwo large-breed dogs underwent delayed surgical repair of pelvic fractures with the aid of a skeletal traction device. Distraction and reduction in the fractures using the skeletal traction device were monitored by direct visualization and intraoperative fluoroscopy. Postoperative radiographs revealed good to near-anatomical bone reduction and fracture alignment without narrowing of the pelvic canal. Both dogs had complete functional recovery with no evidence of neurological deficits. The use of a skeletal traction device should be considered for reduction and fixation of delayed pelvic fractures.

THE ADDING-ON PHENOMENON IN LENKE TYPE I ADOLESCENT IDIOPATHIC SCOLIOSIS

Objective. To analyze the incidence of adding-on phenomenon in the surgery of Lenke type 1 idiopathic scoliosis. Material and Methods. The study included prospective analysis of radiographs of 89 patients (82 females and 7 males) with idiopathic scoliosis who met the criteria for inclusion. The age of patients at the time of surgery ranged from 12 to 25 years (mean: 16.3 ± 4.4 years). The average follow-up period was 2.3 ± 0.4 years. Scoliotic deformity corresponded to grade III according to V.D. Chaklin’s classification in 24 patients, and to grade IV in 65. The magnitude of the primary thoracic curve varied from 30° to 103° of Cobb angle (mean: 61.1° ± 17.1°). In all cases, segmental third generation instrumentation (hybrid or laminar) was used in combination with intraoperative skeletal traction with an afford equal to 50 % of the patient’s body weight. Laminar fixation was used in 6 patients, and hybrid fixation with different extent of screw installation in 83. Results. The following parameters showed significant increase: the magnitude of thoracic curve according to Cobb – 16.0° ± 4.3°, the distance from the center of the vertebra located one level distal to the lowest instrumented vertebra, to the central sacral vertical line (LIV+1-CSVL) – 3.6 ± 2.5 mm, the tilt of the lower instrumented vertebra in the coronal plane (LIV tilt angle) – 3.6° ± 2.8°, the tilt of the vertebra located one level distal to the lowest instrumented vertebra (LIV+1 tilt angle) – 4.6° ± 2.5°, and the distance from the center of the apical vertebra of the primary curve to the central sacral vertical line (AV-CSVL) – 17.2 ± 12.0 mm. A significant correlation was found between postoperative magnitude of the scoliotic curve and AV-CSVL distance, postoperative LIV+1-CSVL distance and postoperative LIV+1 tilt angle. An increase in LIV+1 tilt angle in combination with an increase in LIV+1-CSVL distance by more than 4 mm (or degrees) could be a parameter for measuring the adding-on phenomenon. Conclusion. The indication for reoperation may probably be a significant tilt of the vertebra located below the lowest instrumented vertebra, accompanied by pain syndrome and coronal imbalance.

Distraction Arthrodesis of the Atlantoaxial Facet Joint with Preservation of the C2 Root for the Management of Intractable Occipital Neuralgia Caused by C2 Root Compression

Introduction Vertical collapse of the C1-C2 facet joint may cause narrowing of the C2 root foramen with root compression, resulting in severe occipital neuralgia. The purpose of this study was to evaluate the prospectively collected outcomes data of a distraction arthrodesis surgical group (Study group) in comparison to a Control group in a non-randomized design. Material and Methods The Study group underwent intraoperative skeletal traction, preservation of the C2 nerve roots, facet joint distraction and insertion of a bone block and cancellous bone into the joint along with posterior fusion, and segmental screw fixation using posterior C1 arch screws instead of lateral mass screws. The Control group had C2 root transection with C1-C2 segmental screw fixation and arthrodesis. Inclusion criteria for both groups were (1) occipital neuralgia caused by C2 root compression confirmed by clinical manifestation and imaging studies including radiographs, CT scan, and MRI, (2) intractable pain (VAS≥7) unresponsive to nonoperative treatment, and (3) follow-up period ≥12 months. We compared the preoperative and postoperative 10-point VAS scores for occipital neuralgia and neck pain; NDI; and JOA scores and recovery rates. Results There were 15 patients in the Study group and 8 in the Control group. All had facet joint destruction and/or collapse caused by underlying disorders including rheumatoid arthritis (Study group: 5 ; Control group: 3), rheumatoid arthritis with odontoid nonunion (2, 0), odontoid nonunion (3, 1), unifacet spondylosis (3, 2), os odontoideum (2, 1), and cerebral palsy (0, 1). There was no significant difference in age (61 ± 6, 62 ± 9), gender (4 and 3 men, respectively), and the number of cases with accompanying myelopathy (5, 2) between the 2 groups. The follow-up period averaged 21 ± 12 versus 33 ± 25 months, respectively. There was no significant difference in the VAS score for the preoperative occipital neuralgia (8.2 ± 0.9, 7.9 ± 0.6, p = 0.39). However, it was significantly lower in the Study group at 1, 3, 6, and 12 months postoperatively (p = &lt;0.01, respectively). At 12 months, the VAS was 0.4 ± 0.6 versus 2.5 ± 2.6 ( p = 0.01). In the Study group, all patients had little or no pain (VAS ≤2) while 2 patients (25%) in the Control group were still on medication (Gabapentin) with moderate to severe pain (VAS 4 and 8 respectively). There was no significant difference in preoperative and postoperative VAS scores for neck pain, NDI, and JOA scores and recovery rate, since these values are minimally influenced by occipital neuralgia. Conclusion Our results suggest that our novel technique of distraction arthrodesis can be an effective option for the management of intractable occipital neuralgia caused by C2 root compression. Prospective randomized studies are required for better evaluation.

The Use of Intraoperative Traction in Pediatric Scoliosis Surgery: A Systematic Review

Study DesignSystematic review. ObjectiveTo study the morbidity and the potential benefits of using intraoperative skeletal traction as an adjunct method for correcting scoliosis. Summary of Background DataCotrel et al., used intraoperative skeletal traction in all patients in their original series of segmental spinal instrumentation for scoliosis correction (Cotrel et al., Clin Orthop Relat Res 1988;227:10–23). However, the use of intraoperative traction may introduce other forms of surgical morbidity, which has not been systematically studied. MethodsTwo independent reviewers searched MEDLINE (1948–current) and EMBASE (1980–current) using the keywords scoliosis, intraoperative, and traction in all fields, combined with AND. Studies were subject to full-text assessment against specific inclusion and exclusion criteria; discrepancies between the reviewers were resolved by a third independent reviewer. Data were extracted into standardized extraction tables and papers were critically appraised papers with regards to their relative strengths and weaknesses, with particular attention to the study objective. ResultsNine papers were included: case report (n = 1), retrospective case series (n = 2), retrospective case–control (n = 6), and studies included both adolescent idiopathic scoliosis (AIS) and neuromuscular scoliosis. Seven studies reported positive effects of intraoperative skeletal traction on diverse outcome measures, such as correction of pelvic obliquity, Cobb angle, and axial plane deformity, as well as precluding the need for an anterior release preceding posterior instrumentation for large curves. Overall, there was only one reported postoperative traction-related complication (anterosuperior iliac spine pressure sore). One paper reported that intraoperative traction may evoke neuromonitoring signal changes in a large proportion of patients undergoing AIS surgery. These changes were responded to intraoperatively by decreasing or removing weight and none of the patients had postoperative neurologic deficits. ConclusionIsolated intraoperative skeletal traction may be a low-morbidity adjunct to facilitate scoliosis surgery. Further studies are needed to compare outcomes of scoliosis surgery with or without intraoperative skeletal traction.

Intraoperative Skull-Femoral (Skeletal) Traction in Surgical Correction of Severe Scoliosis (&gt;80°) in Adult Neglected Scoliosis

Retrospective review. To evaluate the effectiveness, safety, and reliability of intraoperative skeletal traction in the surgical correction of severe adult neglected scoliosis. Literature shows that curves more than 80° that do not reduce to 50° to 55° on bending radiographs require an anterior release. A combined anterior and posterior approach is often used for treating severe rigid scoliosis. However, anterior approach has its own complications in the form of increased morbidity, increased blood loss, operative time, and pulmonary complications. Corrective surgery gets even more challenging if the patients are adults. Ten patients with severe scoliosis (>80°) and low flexibility index (<0.5) treated with intraoperative skeletal traction were part of this study. The patients were operated between April 2008 and May 2010. Eight patients with neglected adolescent idiopathic scoliosis and 2 with neuromuscular scoliosis were included. The mean age was 27.4 years (19-36). Corrective surgery and fusion was performed using intraoperative skeletal traction. The Cobb angle improved from a mean of 89.35° preoperatively to 40.25° postoperatively giving a mean correction of 55.29%. Apical vertebral rotation (Nash and Moe) improved from a mean of grade 3(2-4) to a mean of grade 2(1-3). Apical vertebral translation improved from a mean of 2.19 cm preoperatively to 0.98 cm postoperatively (55.41% correction). There were no intraoperative adverse events or postoperative complications. All patients had good shoulder balance and were satisfied with the correction achieved. Intraoperative skull-femoral traction can be a safe and effective method to assist correction of severe and rigid scoliosis. It facilitates surgical exposure and pedicle screw insertion. It obviates the need of an anterior release surgery and associated morbidity, thus reducing the hospital stay and costs. It provides a much simpler way to correct the sagittal and coronal imbalance, as well as the pelvic obliquity.

Closed femoral intramedullary nailing in the lateral decubitus position with the aid of intraoperative skeletal traction

The closed intramedullary nailing is the treatment of choice for femoral diaphyseal fractures. These procedures typically have been performed on a fracture table with either supine or lateral position. However, the use of a fracture table has a lot of disadvantages compared to a lateral position on radiolucent routine table. We reviewed one hundred and twenty-eight patients with femur fractures between 2005 and 2009, who were treated with closed femoral intramedullary nailing in lateral decubitus position on radiolucent routine table. Indirect reduction was facilitated by the aid of intraoperative skeletal traction. Clinical and radiologic results were evaluated. There were no rotational or length malreductions that required surgical revision. There were no injuries to the perineum or contralateral leg, nerve palsies, or fracture table–related complications. There were three cases of non-union and two cases of interlocking screw loosening. Lateral decubitus position obviates the need for fracture table, making it easier to establish an entry point for an intramedullary device. Closed femoral intramedullary nailing in lateral decubitus position with the aid of intraoperative skeletal traction is safe and an effective technique with a low incidence of complications compared to the use of fracture table.

Reviewer’s comment concerning “the effect of intraoperative skeletal (skull-femoral) traction in apical vertebral rotation” by St Lewis et al. (MS-no: ESJO-D-08-00312R1)

This paper by Lewis et al. sets out to quantify the effects of skull-femoral traction on apical vertebral rotations of significant scoliotic curves undergoing surgical intervention. As noted in the paper, there has evolved to be a greater appreciation for the rotational aspect of scoliosis over time. Achieving correction of the Cobb angle and apical rotational aspects of a curvature prior to initiating surgical intervention would be expected to facilitate exposure, instrumentation, and possibly correction of a deformity. Skull-femoral traction is evaluated for this purpose in the current study. The paper did find a significant reduction in Cobb angle and apical vertebral rotation after the application of skull-femoral traction relative to preoperative film measurements. The authors conclude that there are significant potential advantages to this technique. My primary concern with this paper is that the effect of skull-femoral traction is not evaluated as in independent variable as the comparison radiographs were upright preoperative films as opposed to films taken immediately before applying traction. The authors note that there was greater correction than would have been expected with lying the anesthetized patient prone on a surgical frame, but the relative effects of these factors is not evaluated. Clearly, this information is important if the effect of the skull-femoral traction is to be defined. Further, an empirically chosen weight was chosen for the traction. The authors describe approximately 50% of body weight applied through the limbs and 20–25% of body weight applied through the skull as counter-traction. However, there is no suggestion of how these weights were selected. Overall, this paper describes a cohort of patients with significant scoliotic curves for whom skull-femoral traction was used. This is shown to be a technique with significant potential advantages in selected patients. I would suggest that this could be further investigated with the relative effect of graded, skull-femoral traction as an independent variable if the indications and specifics of this technique are to be defined.

The effect of intra-operative skeletal (skull femoral) traction on apical vertebral rotation

The study design is a retrospective review of consecutive case series. Our goal was to identify and quantify the effect of skeletal traction on the apical vertebral rotation (AVR). Intra-operative skeletal traction has been used for the correction of large magnitude idiopathic and neuromuscular scoliosis. The ability of skeletal traction to correct the rotational deformity of the spine has not been characterized. Following REB approval, retrospective analysis of 22 (AIS = 14, neuromuscular = 8) consecutive pediatric patients having surgical posterior instrumented correction and fusion for their scoliosis was performed. Intra-operative skeletal traction with approximately 50% body weight was achieved with smooth distal femoral pins. Counter-traction up to 25% was used through Gardner-Wells tongs. The AVR of the major curve was assessed using the Nash-Moe grading system by a radiologist and a senior spine surgeon not involved in the treatment of these cases. Statistical analysis was performed to determine the significance. The overall mean AVR of the major structural curve was 3.1 +/- 0.8 and reduced to 2.4 +/- 0.6 (p = 0.0001) following traction. The AVR decreased by one or more Nash-Moe grades with traction in 14/22 (64%) patients. The Cobb angle corrected from a mean of 88.2 degrees to 49.1 degrees (44.3%, p = 0.00001) with traction. The decrease in AVR correlated with the higher magnitude Cobb angles (correlation 0.53, p = 0.014). Patients with pre-traction AVR > or = 3 showed the largest change with traction (3.4-2.5, p = 0.000004). There was very good association between the radiologist and the spine surgeon, 0.72(standing films) and 0.63(traction films). The minor structural curve corrected from a mean Cobb of 53.5 degrees to 33.8 degrees (37.8%) with AVR decreasing from a mean of 1.9 to 1.4 (p = 0.014). Significant apical derotation occurs with the use of intra-operative skull-skeletal traction in the correction of high magnitude scoliotic curves. This derotation can facilitate spinal exposure, placement of pedicles screws and final correction in these patients.

Intraoperative skeletal traction in the dog

A standard skeletal traction technique was applied to each major segment of the appendicular skeleton of ten fresh dog cadavers. Opposition points and anchorage points for the application of traction were determined for each skeletal segment. Traction was exerted by means of a micrometric traction stand, connected to the limb by bands or a stirrup. Traction was applied to the antebrachium and the tibia through nylon traction bands anchored to the metacarpus and metatarsus, respectively. A traction stirrup applied to the condylar region was used as the anchorage point to load the humerus and femur. Once a peak force of 25 kg weight was achieved, the load was monitored for half an hour to check for any variation. After that, each skeletal segment was osteotomized in the mid-diaphyseal region, and evaluated for any angular malalignment due to a mismatch between the axis of the bone and the applied loading. Any ensuing angular malalignment was successfully corrected by manoeuvres using the traction stand. The technique used in this study to perform intraoperative skeletal traction proved to be reliable and consistent for each segment of the appendicular skeleton.

Clinical application of intraoperative skeletal traction in the dog

The purpose of this clinical study was to evaluate the technical feasibility of a method for pre-operative and intra-operative traction for reduction of fractures of the appendicular skeleton. Traction was used in 24 diaphyseal fractures in 21 dogs. For each dog, the data pertaining to signalment, limb circumference, fracture type, interval between fracture and surgery, and the traction modalities were recorded. In patients with a latency between trauma and surgery of less than three days, the duration of traction required to realign the bone segments was shorter than that required for older fractures (P = 0.02). Intraoperative malalignments were corrected by manoeuvres performed with the traction stand. Once realigned, fracture segments were kept stable for prolonged periods, without the need for a surgical assistant. Postoperative radiographs were evaluated for fracture reduction and axial alignment. Postoperative alignment was judged excellent in 21 fractures and good in three fractures. Fractures were stabilized using external skeletal fixation (n = 10), plates (n = 11) or locked nails (n = 3), depending on the fracture type. The use of the technique was straight-forward and easily applied in a surgical setting. However, its use requires careful application because of the potential for iatrogenic tissue damage.

Neurologic Complications of Pediatric Femoral Nailing

Summary Neurologic complications of femoral rodding with interlocking nails were investigated in 35 consecutive pediatric patients, aged 10-17 years, with traumatic femur fractures. We examined various risk factors for neurologic complications, including timing and duration of surgery, preoperative and intraoperative traction type, adequacy of preoperative traction, intraoperative patient position, degree of communution of the fracture, and use of interlocking screws. There were eight (22.2%) neurologic complications. Of these, only two (5.6%) persisted for longer than a week. The combination of surgical delay >48 h, preoperative shortening, and the use of boot traction increased the incidence of all palsies to 5.68 times and peroneal palsies to 11.4 times that of patients without this combination of risk factors. Adequate pre- and intraoperative skeletal traction, especially in patients with hours of surgical delay, may decrease the incidence of neurologic complications in pediatric femoral nailings.

Neurologic complications of pediatric femoral nailing.

Neurologic complications of femoral rodding with interlocking nails were investigated in 35 consecutive pediatric patients, aged 10-17 years, with traumatic femur fractures. We examined various risk factors for neurologic complications, including timing and duration of surgery, preoperative and intraoperative traction type, adequacy of preoperative traction, intraoperative patient position, degree of comminution of the fracture, and use of interlocking screws. There were eight (22.2%) neurologic complications. Of these, only two (5.6%) persisted for longer than a week. The combination of surgical delay > 48 h, preoperative shortening, and the use of boot traction increased the incidence of all palsies to 5.68 times and peroneal palsies to 11.4 times that of patients without this combination of risk factors. Adequate pre- and intraoperative skeletal traction, especially in patients with hours of surgical delay, may decrease the incidence of neurologic complications in pediatric femoral nailings.

Closed intramedullary nailing of femoral shaft fractures. A review of one hundred and twelve cases treated by the Küntscher technique.

Since May 1972, the standard treatment of femoral shaft fractures at the Western General Hospital has been the closed femoral nailing technique of Küntscher. We have found that the use of intraoperative skeletal traction eliminates the need for immediate operation, preoperative skeletal traction, or the use of a distraction apparatus to prevent preoperative shortening. By the use of a cross-pinning technique, the closed femoral nailing method has been extended to include severely comminuted fractures of the femoral shaft and fractures of the distal third of the femur, with effective control of shortening and rotatory deformity. This allows early mobilization and discharge from the hospital for patients with these difficult fractures. One hundred and twelve consecutive traumatic fractures of the femoral shaft treated in this manner united within three to six months. The clinical results in terms of early joint movement, early weight-bearing, and rapid discharge from the hospital have been excellent.