When finishing a case with a resident recently, she noted how smoothly the case went despite having struggled with the same procedure in the past. While the technical aspects of the procedure were no different than the other times she helped perform it, she mentioned that the patient position we chose made all the difference. It was a great observation and brings up a point that I think we seldom discuss in lower extremity surgery: patient positioning.
Given the multiplanar anatomic problems we tackle in podiatric surgery, we need to be prepared to approach each unique problem in the necessary position. I briefly discussed this in a previous blog on operating room efficiency but think the topic of patient positioning warrants for discussion.
Here are my three favorite intraoperative patient positions (aside from supine) and the kinds of cases in which these patient positions may be beneficial.
• Prone position. Prone position is useful for many procedures including ankle and hindfoot fusions, a posterolateral or posteromedial incisional approach to ankle fracture reduction, Achilles tendon ruptures, Haglund's disease cases as well as posterior arthroscopy. I am even aware of one surgeon in Columbus, Ohio who placed a patient in this position for a total ankle replacement procedure.
The list can go on. Suffice it to say that the prone position is very useful and often necessary for direct visualization of the posterior anatomy. Surgeons often use prone positioning for the patient when there are no medical contraindications.
• Lateral position. I commonly use the lateral position for a number of pathologies, the most common being for the fixation of calcaneal fractures. This does not change based on my incisional approach as I will do both a sinus tarsi and lateral extensile approach (in the select few instances where I still perform a lateral extensile incision) with the patient in the lateral position.
It is important to note that you can still externally rotate the hip and leg to easily obtain all X-ray views without any difficulty, much like you would when the patient is supine. I have also addressed an isolated fibular fracture with a long posterior spike with the patient in lateral position, which allows for easy access and manipulation of the fracture, and tends to help with the reduction while allowing for syndesmotic fixation if needed.
• “Sloppy lateral” position. Finally, my third favored position and one that I think we undervalue and underutilize is the exaggerated bump of the ipsilateral side, also known as the “sloppy lateral” position. I find this particular option best to address some pathologies of the lateral column and hindfoot.
By far, the procedure which benefits the most from sloppy lateral positioning of the patient is repair of the Jones fracture with intramedullary screw fixation. A typical complication of this procedure technically is the difficult throw of the guide wire across the fracture and into the intramedullary canal of the fifth metatarsal. Trying to do this in the supine position only leads to further awkward hand positioning, making it difficult to accomplish. With the patient and entire leg placed in a sloppy lateral position, this initial wire throw is much easier to perform and the entirety of the case becomes much easier. (Another tip for this case unrelated to positioning is to start the wire by finding your position on X-ray and then gently malleting it into the fifth metatarsal base before driving the wire with your power driver.)
I will also do almost all my lateral column procedures in this position with ease and prefer it to the standard supine position.
These are my three favored intraoperative patient positions to approach a variety of cases. If you have not tried one or all of them, I hope you will soon. It can be remarkable to appreciate the ease with which you can perform some of the aforementioned procedures from a different position other than the supine position.
Dr. Rahnama is a fellowship-trained foot and ankle surgeon and an Assistant Professor at the Georgetown University School of Medicine in Washington, D.C. You can follow him on Instagram @DrAliRahnama for interesting cases and educational material.