Functional Application of Tricks for Super Obese Patient Positioning: A Technical Guide for Hip Fractures on a Fracture Table With a Case Example

Abstract

Obese patients with hip fractures are at increased risk of perioperative complications due to both their size and associated medical conditions. The purpose of this report is to describe a technique for intraoperative positioning of obese patients who sustain a hip fracture. A 62-year-old female with a history of morbid obesity (BMI 48.06kg/m²), type II diabetes mellitus, and hypertension presented with a right intertrochanteric fracture and was admitted for operative fixation on a fracture table. A standardized approach for systematic patient positioning and abdominal panniculus taping is described, which facilitates operative repair of the hip fracture using a cephalomedullary nail. This report describes the intraoperative positioning technique of a morbidly obese patient with an intertrochanteric hip fracture in order to highlight specific techniques used to deal with the physical aspects of obesity that can improve the surgical efficiency of the procedure. By positioning obese patients in a standardized way, intraoperative time and complications will be decreased, potentially mitigating some of the risks associated with this patient population.

Keywords: elderly; hip fracture; intraoperative positioning; obese; technique.

Figure 1. Initial Imaging

Anteroposterior radiograph of the right hip demonstrating OTA/AO type 31A1.2 intertrochanteric fracture. The abdominal panniculus fold, extending 10cm distal to the tip of the greater trochanter and outlined in red, is overlying the anterior and lateral aspect of the right hip joint. OTA/AO: Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen

Figure 2. Example of Pannus

Representative patient images demonstrating abdominal panniculus overhanging planned surgical site in the frontal (a) and sagittal (b) planes.

Figure 3. Positioning on Fracture Table

a. Patient’s operative extremity is placed in a padded fracture boot and further secured with Coban^TM. b. Patient’s non-operative extremity is scissored below the level of the operative extremity, and the lower leg is wrapped with a pillow and secured to the fracture table. The non-operative extremity is slightly externally rotated to ensure it is not in line with the operative leg, as doing so may complicate obtaining fluoroscopic images.

Figure 4. Systematic Abdominal Panniculus Taping

A. Mastisol® is used to create a sticky surface on the skin that is also protective against skin tears. Surgical tape (silk) is then placed on the Mastisol® to create a “landing strip” to which additional tape can adhere for different vectors of pull. B. Tape in this orientation is used to pull the patient’s ipsilateral breast proximally out of the surgical field. C. Tape is placed on the patient’s midline and extended towards the opposite side and secured to the table in order to pull the central abdominal panniculus and remainder of the mid-torso excess soft tissue away from the patient’s midline. D. The patient’s ipsilateral arm is placed over her chest, pulled towards the contralateral side and taped to the bed to rotate the upper torso towards the patient’s contralateral side. E. Note the wide exposure of the proximal hip that is free of overhanging central abdominal panniculus and soft tissue that allows for improved access to the starting point for the intramedullary nail (compared to Figure 5C) where the contralateral hip is completely obscured by the patient’s central abdominal panniculus and mid-torso soft tissue.

Figure 5. Contralateral Side

A. Horizontal strips of silk tape are secured to the patient’s abdominal panniculus, pulled towards the contralateral side and secured to the table. B. Ipsilateral arm positioned over the patient’s chest with silk tape used to secure the arm. This same tape is also pulling the patient’s ipsilateral breast away from the surgical field. C. Note the abundance of abdominal panniculus that is overhanging the patient’s contralateral hip completely obscuring the operative site at the proximal hip precluding insertion of an intramedullary nail.

Figure 6. Start Point with Awl

A curved cannulated awl (a) is used to obtain the start point, allowing for penetration of subcutaneous tissue and medial pressure against the lateral soft tissues (b) to maintain control of the tip of the awl (c).

Figure 7. Lateral Excursion Jig

A percutaneous jig with extra lateral excursion is used for percutaneous lag screw placement to avoid impingement of soft tissues on the jig.

Figure 8. Final Fluoroscopy

Final fluoroscopic images demonstrate acceptable fracture reduction and implant position.