Traction

Sciatica and Back Pain Self-Treatment

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For optimal viewing and safe surgery, at least 1.2 cm of distraction is required of the femoroacetabular joint. Two commercial distractors for the lateral approach are available from OSI and Innomed (Savannah, GA), designed by Dr. Glick and Dr. Joseph McCarthy, respectively. The OSI distractor has many advantages in that hip motion is adjustable during surgery and it has a continuous readout tensiometer.

Chic Fracture Table

FIGURE 9.5. (A) Traditional fracture tables with the Chick table traction using a Buck's device and a wall pulley with 45 lb trac-

showing the vertical posterior peroneal post on the left, which tion. The right view shows patient in the original lateral trac-

may impinge against the sciatic nerve with traction and the leg tion for shoulder arthroscopy using wall pulleys, rope, and in extension. (B) The left image shows a patient in abduction weights.

FIGURE 9.5. (A) Traditional fracture tables with the Chick table traction using a Buck's device and a wall pulley with 45 lb trac-

showing the vertical posterior peroneal post on the left, which tion. The right view shows patient in the original lateral trac-

may impinge against the sciatic nerve with traction and the leg tion for shoulder arthroscopy using wall pulleys, rope, and in extension. (B) The left image shows a patient in abduction weights.

Pulley Used Sciatica

FIGURE 9.6. The Hip Distraktor (Arthronix; no longer available) attached to the traction hand-driven screw, which can be positioned allows for the use of most operating room tables. A rack supports in various degrees of flexion, abduction, and rotation. A tensiome-the leg, preventing valgus forces on the knee, and the foot piece is ter measures the relative forces applied.

FIGURE 9.6. The Hip Distraktor (Arthronix; no longer available) attached to the traction hand-driven screw, which can be positioned allows for the use of most operating room tables. A rack supports in various degrees of flexion, abduction, and rotation. A tensiome-the leg, preventing valgus forces on the knee, and the foot piece is ter measures the relative forces applied.

Implan Orif Femur

FIGURE 9.7. The OSI Hip distractor on the Jackson table. Note the C-arm is brought beneath the table. The patient's leg can be positioned in varying angles of rotation, flexion, extension, abduction, and adduction. A digital readout tensiometer is used to monitor the traction. The peroneal post has more than 9 cm of padding.

FIGURE 9.7. The OSI Hip distractor on the Jackson table. Note the C-arm is brought beneath the table. The patient's leg can be positioned in varying angles of rotation, flexion, extension, abduction, and adduction. A digital readout tensiometer is used to monitor the traction. The peroneal post has more than 9 cm of padding.

Leg Traction
FIGURE 9.8. Patient is lying on a fluoroscopic table in the Innomed hip distractor. Note there is no tensiometer and the leg cannot be flexed or extended once positioned; however, rotation is possible.

FIGURE 9.9. The Glick Hip Set (Stryker). Note the long arthroscope as well as long instruments and sheaths.

FIGURE 9.10. Slotted cannula allowing introduction of curved instruments into the hip joint.
Femoral Head Neck Excision Instruments

FIGURE 9.11. Dyonics system of sheaths that fit a standard Dyonics arthroscope. Additional instruments are a 14-gauge intracath, no. 11 blade, slotted cannula, switching sticks, and Nitanol wire as well as a syringe with marcaine and epinephrine.

Hip Arthroscopy Cannulas

FIGURE 9.12. Operating room layout. Note the patient is in an OSI distractor, and the surgeon and technician are anterior to the patient with the assistant posterior. The C-arm lies between the surgeon and the technician. A Mayo stand lies above the patient for organization of the cords coming from the tower, which is opposite the surgeon. The anesthesiologist is above the head and out of the way.

FIGURE 9.12. Operating room layout. Note the patient is in an OSI distractor, and the surgeon and technician are anterior to the patient with the assistant posterior. The C-arm lies between the surgeon and the technician. A Mayo stand lies above the patient for organization of the cords coming from the tower, which is opposite the surgeon. The anesthesiologist is above the head and out of the way.

FIGURE 9.13. (A) The patient is lying in a lateral decubitus position with the peroneal post in place. Note the posterior lumbosacral support preventing rollback on the peroneal post. (B) Anterior view of the peroneal post with adequate padding. Note there is adequate space beneath the post, not compressing on the downside leg and offsetting the post toward the operating leg, taking pressure off the pudental nerve.

FIGURE 9.13. (A) The patient is lying in a lateral decubitus position with the peroneal post in place. Note the posterior lumbosacral support preventing rollback on the peroneal post. (B) Anterior view of the peroneal post with adequate padding. Note there is adequate space beneath the post, not compressing on the downside leg and offsetting the post toward the operating leg, taking pressure off the pudental nerve.

Safe traction should be viewed the same as safe tourniquet time and pressure. With the use of evoked potentials, it has been determined that traction forces less than 75 lb for less than 2 hours is safe.5 I try for traction at less than 50 lb for less than 1 hour to allow for a large margin of safety, and as a result have had no traction-related complications since the technique was implemented.

Realize, however, that "complications may occur from too little or too much traction" (J.M. Glick, personal communication, 2002), and to accomplish the procedure the joint surfaces must be separated to introduce instruments.

The perineal post should have padding of at least 9 cm in diameter and be positioned eccentrically over the pubic symphysis with no compression on the downside thigh. I initiate traction after the case is entirely set up and all the equipment has been turned on and is functioning. We record the traction time and force, which is entered in the record with the vital signs.

Once the intraarticular portion of the surgery is finished, all the distraction forces are released and the periarticular work can be done without traction concerns.

operating room setup

Leg Position

In traction, the hip capsule is maximally relaxed in 15 degrees of flexion, neutral rotation, and 15 degrees of abduction. I use this as a starting position and make adjustments during the procedure. Additionally, the perineal post may be elevated laterally to add an abduction moment for better viewing (Figure 9.15).

FIGURE 9.14. (A) The C-arm is beneath the patient's table and is brought to the level of the hip joint. The monitor sits across from the surgeon. (B) View of the C-arm from the surgeon's position anterior to the patient. Note it is out of the way of surgery.

Instruments

The 30-degree arthroscope is best for central viewing. It is easier to get oriented with this angle, and it is the best for getting started. On thin patients standard arthroscopic equipment may be used if the sheath has a short hub. The advantages of the hip kits are that they contain the proper sheath lengths and cannulated systems. The 70-degree ?arthroscope is best for peripheral viewing and is used to look around the femoral head and to create additional portals. The option for longer arthro-scopes should be available for larger patients and for cases in which there is excessive swelling of the thigh.

Both straight and curved graspers are necessary as well as straight and curved shavers (Figure 9.16). To insert curved instruments, a slotted cannula or a flexible plastic sheath is used.

One of the radiothermal probes is used for coagulation, cutting, and ablation of tissues such as capsule or labrum. Because most of these are bendable devices, they can reach the lesion when the metal instruments cannot. The Oratec wands conceived by Marc Philip-pon and designed for hips can be manually flexed with a trigger handle (Figure 9.17).

Angled neurocurrettes and angled picks are used to treat arthritic defects and remove attached and loose bodies located in difficult areas such as the medial ac-etabular notch and anteromedial acetabulum.

The Pump and monitored. I recommend using an outflow-dependent pump such as the Stryker Pump, which was designed to work with less fluid demand and that reduces the chance of extravasation into the soft tissues. The pump pressure is set the same as the shoulder or slightly above diastolic pressure.

The Tower

The arthroscopic tower with the monitor and instrument boxes should be placed posterior and slightly cephalad adjacent to the C-arm for optimal viewing of all the settings by the surgeon (Figure 9.18). Think of the surgeon as the pilot of an aircraft. The pilot would not have control of the plane if he or she depended

FIGURE 9.16. Specialized instruments that have longer dimensions and curves to reach around the femoral head or into the acetabulum.

It is generally acceptable to use a pump system because the exact pressure and flow can be controlled

FIGURE 9.16. Specialized instruments that have longer dimensions and curves to reach around the femoral head or into the acetabulum.

Uncovered Femoral Head

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