(FLiP) fracture-table vs. lateral positioning for femoral intramedullary nailing: A survey of orthopaedic surgeon preferences

• Published in: Injury 2020-02, Vol.51 (2), p.429-435
• Main Authors: Rubinger, Luc, Axelrod, Daniel, Bozzo, Anthony, Gazendam, Aaron, Al-Asiri, Jamal, Johal, Herman
• Format: Article
• Language: English
• Subjects: Femur fracture; Intramedullary nailing; Lateral positioning; Surgeon survey; Traction; Traction-table
• ISSN: 0020-1383; 1879-0267
• DOI: 10.1016/j.injury.2019.10.067

•There remains a lack of consensus in the optimal positioning of patients undergoing antegrade nailing for femoral shaft fractures.•Supine positioning with traction remains the most popular choice, especially among community surgeons.•There is a paucity of high-level clinical data to guide decision making with regards to positioning.•Lateral positioning has the potential for fewer traction related complications and improved clinical outcomes.•There is a clear need and desire for more robust data to guide clinical practice. Femoral shaft fractures are common and severe injuries that often occur alongside other complex, high-energy injuries. Definitive internal fixation using reamed, locked intramedullary nailing (IMN) has become the standard of care in adequately resuscitated patients, commonly performed in the supine position with utilization of a fracture table. The lateral position, without the use of traction, offers an alternative that may be associated with lower complication rates. Given the lack of high-quality evidence in the area, this study was designed to assess the attitudes, knowledge base and preferences of Orthopaedic surgeons regarding patient positioning during antegrade IMN of femoral shaft fractures. Orthopedic surgeon members of the AO North America, Canadian Orthopaedic Association and the Ontario Orthopaedic Association were invited to participate in a web-based survey addressing the management of femoral shaft fractures and the need for further research in this area. Most surgeons (56%) favored treating mid-shaft femur fractures in the supine position using a fracture table compared to supine/sloppy lateral (29%) or direct lateral (12%) with the leg free draped. Canadian surgeons showed a significantly higher preference for supine positioning with a fracture table when compared to their American colleagues. Academic and higher-level trauma center surgeons were more likely to prefer the sloppy lateral or direct lateral positioning with manual traction compared to community surgeons. The most commonly cited perceived barrier for utilizing the lateral position was expertise and lack of available assistants. Forty-five percent of respondents expressed interest in being involved in a randomized control trial comparing lateral positioning vs. supine with traction. Consensus surrounding the positioning and utilization of traction in femoral shaft fractures is lacking. Given the perceived possible benefits and reduced complications using the