Operating rooms (ORs) are environments that demand precision, attention to detail, and a deep commitment to patient safety. Among the various tools and positioning devices used during surgical procedures, stirrups play a critical role, especially in gynecologic, urologic, and colorectal surgeries. However, improper use of stirrups can pose significant risks, particularly when it comes to nerve injuries.
This blog explores the relationship between stirrup usage and nerve injury in the OR and outlines strategies to prevent harm while enhancing patient outcomes.
Understanding Stirrups in Surgical Settings
Surgical stirrups are devices designed to support and position a patient’s legs during procedures, typically in the lithotomy position. These devices allow for better access to the surgical site, improved visualization, and ergonomic comfort for the surgical team. There are several types of stirrups used in modern ORs, including:
- Candy cane stirrups: Metal rods with padded supports that cradle the patient’s legs. These are cost-effective but offer limited positional support.
- Boot-type stirrups (Allen or Yellofin): Enclosed boots that support the lower legs and heels, with adjustable positioning for optimal control and distribution of pressure.
While stirrups are invaluable for certain procedures, improper positioning or prolonged use can result in complications, particularly involving the nerves.
Common Nerve Injuries Linked to Stirrups
Improper stirrup use can lead to compression or stretching of nerves, resulting in temporary or even permanent damage. The most commonly affected nerves include:
1. Peroneal Nerve
- Risk factor: Compression at the fibular head from external pressure.
- Symptoms: Foot drop, numbness on the top of the foot.
- Cause: Often linked to improperly positioned candy cane stirrups, where the lateral aspect of the leg rests against the metal.
2. Femoral Nerve
- Risk factor: Excessive hip flexion and abduction.
- Symptoms: Weakness in the quadriceps, difficulty walking, and reduced patellar reflex.
- Cause: Overextension or improper angling of boot-style stirrups.
3. Sciatic Nerve
- Risk factor: Excessive hip flexion and external rotation.
- Symptoms: Buttock pain, leg weakness, tingling in the lower extremity.
- Cause: Prolonged lithotomy positioning with improper leg support.
4. Obturator and Saphenous Nerves
- Risk factor: Stretching due to wide leg separation or poor padding.
- Symptoms: Numbness in the inner thigh (obturator), medial leg (saphenous).
These nerve injuries may manifest post-operatively, sometimes hours or days after the procedure, complicating diagnosis and treatment.
Risk Factors Beyond the Stirrups
While the stirrups themselves can cause nerve injury, several contributing factors must also be considered:
- Patient BMI: Obese patients may have increased pressure on nerve points.
- Procedure length: The longer the surgery, the higher the risk of prolonged nerve compression.
- Pre-existing conditions: Diabetes and peripheral neuropathy increase susceptibility.
- Lack of intraoperative repositioning: Patients kept static for hours face increased ischemic pressure.
Thus, stirrup safety should be viewed holistically, considering equipment, technique, and patient-specific factors.
Best Practices for Stirrup Safety in the OR
Preventing nerve injuries begins with a commitment to protocol, education, and vigilance. Here are the best practices to ensure stirrup safety:
1. Select the Right Type of Stirrups
Depending on the procedure type and patient characteristics, candy cane and boot-style stirrups should be chosen. Boot stirrups offer better weight distribution and support, reducing pressure on individual nerves.
2. Use Proper Padding
Ensure all contact points—especially at the calf, ankle, and thigh—are adequately padded. This minimizes pressure points and friction.
3. Position with Precision
Use the following guidelines for ideal positioning:
- Hips: Flexed 80–100 degrees.
- Knees: Flexed 70–90 degrees.
- Thighs: No more than 45 degrees abduction.
- Avoid excessive external rotation.
Symmetry is crucial. Both legs should be positioned simultaneously to reduce strain on the pelvis and spine.
4. Involve the Entire Surgical Team
Positioning should be a team responsibility. Involve nurses, anesthesiologists, and the surgical team to assess alignment, verify documentation, and periodically reassess throughout the procedure.
5. Limit Time in Lithotomy Position
Whenever possible, minimize the duration of time a patient is kept in stirrups. For long procedures, consider adjusting the patient’s position during natural breaks to restore circulation.
6. Conduct Preoperative Risk Assessments
Include stirrup-related risks in preoperative planning, particularly for high-risk patients. Document nerve status prior to surgery and obtain informed consent discussing potential complications.
7. Postoperative Monitoring
Surveillance for symptoms such as numbness, tingling, or muscle weakness should begin in recovery. Early detection facilitates timely intervention.
Technology and Innovation in Stirrup Safety
Emerging technologies are enhancing stirrup safety through better design and monitoring. Innovations include:
- Pressure-distributing stirrups: Advanced materials that adapt to the patient’s anatomy and reduce focal pressure points.
- Integrated sensors: Some stirrups are equipped with pressure sensors that alert clinicians to high-risk zones in real-time.
- Modular designs: Allow easy adjustment of angles and support, improving customization and patient safety.
Hospitals that invest in such technologies often see improved patient outcomes and reduced malpractice risk.
Legal and Ethical Considerations
Nerve injury due to stirrup use can lead to significant legal ramifications. Proper positioning, padding, and periodic checks must be documented for liability protection. Ethical considerations also demand that patients be informed of positioning-related risks, especially for elective procedures.
Case Study: A Cautionary Tale
A 45-year-old woman underwent a laparoscopic hysterectomy. She was positioned in candy cane stirrups for nearly four hours. Post-operatively, she reported numbness and inability to dorsiflex her foot, diagnosed as peroneal nerve palsy. Despite physical therapy, her condition persisted, resulting in a lawsuit.
An internal review revealed:
- Inadequate padding.
- Extended surgery duration.
- No intraoperative repositioning.
The case underscores the vital importance of vigilance and adherence to safety protocols when using stirrups.
Stirrups Deserve Your Attention
Stirrups may seem like routine tools in the OR, but their impact on patient safety is anything but trivial. Proper use, positioning, and monitoring can prevent devastating nerve injuries, reduce hospital stays, and improve long-term surgical outcomes. By investing time in training, equipment upgrades, and protocol adherence, surgical teams can transform a potential hazard into a well-managed aspect of care.
Remember: in the high-stakes world of surgery, even the smallest device—like a stirrup—can have a lasting impact.
