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Shoulder arthroscopy with the patient in the beach-chair position
Arthroscopy: The Journal of Arthroscopic and Related Surgery 4(4):256-259
Published by Raven Press, Ltd. © 1988 Arthroscopy Association of North America
Shoulder Arthroscopy with the Patient in the Beach-Chair Position M i c h a e l J. S k y h a r , M . D . , D a v i d W . A l t c h e k , M . D . , R u s s e l l F . W a r r e n , M . D . , T h o m a s L . W i c k i e w i c z , M . D . , a n d S t e p h e n J. O ' B r i e n , M . D .
Summary: We evaluated the use of the beach-chair, or sitting, position for arthroscopic shoulder surgery in 50 consecutive patients. Routine arthroscopy, arthroscopic subacromial decompression, and arthroscopic shoulder stabilizations were performed, with no complications. The advantages of this position include ease of setup, lack of brachial plexus strain because no traction is used, excellent intraarticular visualization for all types of arthroscopic shoulder procedures, and ease of conversion to the open approach if needed. The positioning technique is described. Key Words: Shoulder--Beach-chair position.
Shoulder arthroscopy is most commonly performed with the patient in some variation of the lateral decubitus position (1,2)'. Since certain problems are associated with using this position (mainly brachial plexus strain) (3), we have investigated the use of the beach-chair sitting position for shoulder arthroscopy. This is a report of our experience with, and evaluation of, this positioning method. The surgical procedures for which we have used the beach-chair position have included diagnostic arthroscopy, arthroscopic subacromial decompression, and arthroscopic anterior shoulder stabilization.
and a folded sheet placed between the scapulae (Fig. 1). For arthroscopic shoulder stabilization, the patient's affected side is moved off the edge of the table to the medial border of the scapula. A 10-1b (4.5-kg) sandbag is placed under the ipsilateral hip to facilitate rotation of the patient's upper torso at least 30° away from the edge of the table. This allows better access to the posterior aspect of the shoulder, which is important when performing arthroscopic stabilization procedures in which sutures are passed across the glenoid cavity (Fig. 2). As the sutures will exit posteromedially the patient must be positioned correctly to accommodate this, and may be taped in this position for extra support. If a beanbag is available, it alone may be used to attain the above positions correctly and easily. The arm is not placed in traction and is allowed to hang free. An arm board is used on the side of the table at the level of the elbow. The patient is draped for routine shoulder surgery. Standard arthroscopy is performed using a posterior portal for routine diagnostic evaluation. The arm can be manipulated easily into any position by an assistant, as needed, to visualize the entire joint. The alternate arthroscopic portals, including anterior, midlateral, and superior (Neviaser), can be used easily without awkward hand positioning on the part of the surgeon or the need for an "anterior assistant" as in the lateral position.
DESCRIPTION OF THE POSITION The patient is placed on a standard operatingroom.table. General anesthesia or interscalene block is then administered. The table is adjusted so that the patient is sitting up at a minimum of 60°. When the surgeon is performing subacromial decompression and routine shoulder arthroscopy, the patient's shoulder is brought off the side of the table From the Sports Medicine and Shoulder Service, Hospital for Special Surgery affiliated with New York Hospital-Cornell University Medical College New York, New York. Address correspondence and reprint requests to Russell F. Warren, M.D., Hospital for Special Surgery, 535 East 70 Street, New York, NY 10021, U.S.A.
256
SHOULDER ARTHROSCOP Y: BEACH-CHAIR POSITION
257
1A,B
FIG. 1. A: Routine beach-chair position, frontal view. B: Posterior view.
We have found two other portals useful especially for stabilization: the anterosuperior and the posteroinferior. The anterosuperior portal is located just anterior to the acromion and allows excellent visualization of the anterior glenoid cavity and labrum (Fig. 3). The posteroinferior portal is located - 2 cm above the posterior axillary fold and enters the joint in the axillary recess. The path of the posteroinferior portal traverses the rotator cuff near the interval between the infraspinatus and teres minor. Provided the portal is not directed caudally, the axillary nerve and posterior humeral circumflex artery are not in jeopardy. This portal is useful for the inflow cannula (Fig. 4). CLINICAL EXPERIENCE In the period from June 1987 to January 1988, 50 patients underwent an arthroscopic shoulder proce-
dure in the beach-chair position at the Hospital for Special Surgery: 15 patients underwent arthroscopic anterior capsulorrhaphy by either the suture or absorbable staple technique (R. F. Warren, personal communication), 20 had either a diagnostic arthroscopy or an intraarticular soft tissue debridement, and 15 underwent arthroscopic subacromial decompression (90% of these patients were anesthetized with an interscalene block and light sedation). There were no operative or anesthetic complications, or nerve palsies. In no patient was there believed to be a problem with visualization within the arthroscopic operative field. Patient positioning took less time than with the lateral position. Conversion to an open procedure was required in three cases. Two were large rotator cuff tears that necessitated open treatment and one was a conversion to an open shoulder stabilization for multidirectional instability. Arthroscopy, Vol. 4, No. 4, 1988
258
M. J. S K Y H A R E T AL.
FIG. 3. Location of anterosuperior portal (arrow).
FIG. 2. Beach-chair position for performing stabilization. Note medial scapular border at edge of table.
cluded that the best combination of positions to optimize the arthroscopic view and minimize plexus strain was 45 ° forward flexion with 90° abduction, and 45 ° forward flexion with 0° abduction. The position resulting in the least strain was 90° forward flexion and 0° abduction. Among the positions producing the most strain was 30° forward flexion with 70° abduction (3). Of 50 patients in Ellman's series of arthroscopic subacromial decompressions, three patients had transient dorsal digital nerve palsies of the thumb, secondary to arm traction during the procedure (7). Pitman, who used somatosensory evoked potentials to study neuropraxia during shoulder arthroscopy using arm traction, concluded
DISCUSSION Most reports describing the technique of shoulder arthroscopy advise the use of some variation of arm traction while the patient is in the lateral decubitus position (1,2). The use of arm traction for this procedure is not benign. The structure at greatest risk is the brachial plexus (4). In 1985, Paulos reported a nearly 30% incidence of transient parathesias in the upper extremity following shoulder arthroscopy using traction (5). Andrews and Carson described two ulnar and one musculocutaneous transient neuropraxias believed to be related to the use of traction (6). The experience of Klein et al. at the University of Pittsburgh has included an -10% incidence of transient paresthesias and palsies combined (3). For this reason, Klein et al. applied traction (5-25 lbs or 2.25-11.25 kg) to cadaver arms and measured the resultant brachial plexus strain. By relating arm position to plexus strain measurements, they conArthroscopy, VoL 4, No. 4, 1988
FIG. 4. Location of posteroinferior portal (arrow),
SHOULDER A R T H R O S C O P Y: BEACH-CHAIR P O S I T I O N
that the incidence of subclinical transient neuropraxia is high, and probably related to the amount of traction, arm positioning, and joint distention. The musculocutaneous nerve was most frequently involved (8). Is traction really necessary for shoulder arthroscopy? We have had a very positive experience using the beach-chair position without traction on the arm. There are several advantages to this position. Patient positioning is faster and easier. The upright position is much more physiologic in terms of all types of anesthesia techniques. There is no need to reprepare and drape the patient if an open procedure needs to be performed following the arthroscopy, provided sterility has not been broken. When the patient is in the beach-chair position, the capsular anatomy within the glenohumeral joint is not placed in the nonanatomic, stretched-out attitude that occurs with arm traction. This is important for performing arthroscopic capsular reattachment, because of the necessity of obtaining an accurate assessment of glenohumeral ligament laxity in addition to reapproximating tissues under minimal tension. There is more mobility of the arm in the beach-chair position, enabling the assistant to facilitate the field of view by various arm manipulations. A complete view of the entire glenohumeral anatomy is possible with minimal arm manipulation. When the surgeon is performing subacromial decompression, the weight of the arm provides enough downward traction to allow for easy visualization of the space. The ability to manipulate the arm into many different positions with the option of applying variable degrees of intermittent manual traction is useful. In fact, specific arm positioning is critical when attempting arthroscopic rotator cuff repair and stabilization. With the patient's arm at the side, external anatomy is easier to visualize and palpate, especially the coracoid, which is a critical landmark for placement of the anterior portal (9). Access to the anterior aspect of the shoulder is easier when the arm is not suspended within the operative field. The only disadvantage to this position that we have noted is fogging of the camera due to the irrigation solution running down the scope. When the patient is in the beach-chair position, it is necessary to place the arthroscope in the "uphill" position during certain procedures, most notably subacromial decompression. This problem can be limited
259
FIG. 5. Rubber cap placed onto the sheath decreases effluent onto the camera, minimizing fogging.
by minimizing effluent onto the scope during the procedure and solved by newer "fog-free" arthroscopic equipment. The rubber cap from the Acufex disposable cannula system decreases effluent down the scope onto the camera when placed over the arthroscopic sheath (Fig. 5). In summary, placing the patient in the beachchair position for shoulder arthroscopy is simple, prevents potential neurological complications due to traction, and still allows excellent visualization for all types of arthroscopic shoulder procedures. REFERENCES 1. Andrews JR, Carson WG, Ortega K. Arthroscopy of the shoulder: technique and normal anatomy. A m J Sports M e d 1984;12:1-7. 2. Gross RM, Fitzgibbons TC. Shoulder arthroscopy: a modified approach. Arthroscopy 1985; 1:156-9. 3. Klein AH, France JC, Mutschler TA, Fu FH. Measurement of brachial plexus strain in arthroscopy of the shoulder. Arthroscopy 1987;3:45-52. 4. DePalma A. Surgery o f the shoulder. 3rd ed. Philadelphia: JB Lippincott, 1983:35~4. 5. Paulos L. Arthroscopic shoulder decompression: technique and preliminary results. In: North American Arthroscopy Association Annual Meeting, Apt 1985. 6. Andrews JR, Carson WG. Arthroscopic surgery of the shoulder. In: Parisien JS, ed. Arthroscopic surgery. New York: McGraw-Hill, 1988:231--41. 7. Ellman H. Arthroscopic subacromial decompression: analysis of one to three year results. Arthroscopy 1987;3:173-81. 8. Pitman MI. Arthroscopic research. In: Abstracts on sports injuries and rehabilitation, 1%21 Nov 1987, Roosevelt Hotel, New York, NY. 9. Matthews LS, Zarins B, Michae ! RH, et al. Anterior portal selection for shoulder arthroscopy. Arthroscopy 1985;1: 33-9.
Arthroscopy, Vol. 4, No. 4, 1988
Published by Raven Press, Ltd. © 1988 Arthroscopy Association of North America
Shoulder Arthroscopy with the Patient in the Beach-Chair Position M i c h a e l J. S k y h a r , M . D . , D a v i d W . A l t c h e k , M . D . , R u s s e l l F . W a r r e n , M . D . , T h o m a s L . W i c k i e w i c z , M . D . , a n d S t e p h e n J. O ' B r i e n , M . D .
Summary: We evaluated the use of the beach-chair, or sitting, position for arthroscopic shoulder surgery in 50 consecutive patients. Routine arthroscopy, arthroscopic subacromial decompression, and arthroscopic shoulder stabilizations were performed, with no complications. The advantages of this position include ease of setup, lack of brachial plexus strain because no traction is used, excellent intraarticular visualization for all types of arthroscopic shoulder procedures, and ease of conversion to the open approach if needed. The positioning technique is described. Key Words: Shoulder--Beach-chair position.
Shoulder arthroscopy is most commonly performed with the patient in some variation of the lateral decubitus position (1,2)'. Since certain problems are associated with using this position (mainly brachial plexus strain) (3), we have investigated the use of the beach-chair sitting position for shoulder arthroscopy. This is a report of our experience with, and evaluation of, this positioning method. The surgical procedures for which we have used the beach-chair position have included diagnostic arthroscopy, arthroscopic subacromial decompression, and arthroscopic anterior shoulder stabilization.
and a folded sheet placed between the scapulae (Fig. 1). For arthroscopic shoulder stabilization, the patient's affected side is moved off the edge of the table to the medial border of the scapula. A 10-1b (4.5-kg) sandbag is placed under the ipsilateral hip to facilitate rotation of the patient's upper torso at least 30° away from the edge of the table. This allows better access to the posterior aspect of the shoulder, which is important when performing arthroscopic stabilization procedures in which sutures are passed across the glenoid cavity (Fig. 2). As the sutures will exit posteromedially the patient must be positioned correctly to accommodate this, and may be taped in this position for extra support. If a beanbag is available, it alone may be used to attain the above positions correctly and easily. The arm is not placed in traction and is allowed to hang free. An arm board is used on the side of the table at the level of the elbow. The patient is draped for routine shoulder surgery. Standard arthroscopy is performed using a posterior portal for routine diagnostic evaluation. The arm can be manipulated easily into any position by an assistant, as needed, to visualize the entire joint. The alternate arthroscopic portals, including anterior, midlateral, and superior (Neviaser), can be used easily without awkward hand positioning on the part of the surgeon or the need for an "anterior assistant" as in the lateral position.
DESCRIPTION OF THE POSITION The patient is placed on a standard operatingroom.table. General anesthesia or interscalene block is then administered. The table is adjusted so that the patient is sitting up at a minimum of 60°. When the surgeon is performing subacromial decompression and routine shoulder arthroscopy, the patient's shoulder is brought off the side of the table From the Sports Medicine and Shoulder Service, Hospital for Special Surgery affiliated with New York Hospital-Cornell University Medical College New York, New York. Address correspondence and reprint requests to Russell F. Warren, M.D., Hospital for Special Surgery, 535 East 70 Street, New York, NY 10021, U.S.A.
256
SHOULDER ARTHROSCOP Y: BEACH-CHAIR POSITION
257
1A,B
FIG. 1. A: Routine beach-chair position, frontal view. B: Posterior view.
We have found two other portals useful especially for stabilization: the anterosuperior and the posteroinferior. The anterosuperior portal is located just anterior to the acromion and allows excellent visualization of the anterior glenoid cavity and labrum (Fig. 3). The posteroinferior portal is located - 2 cm above the posterior axillary fold and enters the joint in the axillary recess. The path of the posteroinferior portal traverses the rotator cuff near the interval between the infraspinatus and teres minor. Provided the portal is not directed caudally, the axillary nerve and posterior humeral circumflex artery are not in jeopardy. This portal is useful for the inflow cannula (Fig. 4). CLINICAL EXPERIENCE In the period from June 1987 to January 1988, 50 patients underwent an arthroscopic shoulder proce-
dure in the beach-chair position at the Hospital for Special Surgery: 15 patients underwent arthroscopic anterior capsulorrhaphy by either the suture or absorbable staple technique (R. F. Warren, personal communication), 20 had either a diagnostic arthroscopy or an intraarticular soft tissue debridement, and 15 underwent arthroscopic subacromial decompression (90% of these patients were anesthetized with an interscalene block and light sedation). There were no operative or anesthetic complications, or nerve palsies. In no patient was there believed to be a problem with visualization within the arthroscopic operative field. Patient positioning took less time than with the lateral position. Conversion to an open procedure was required in three cases. Two were large rotator cuff tears that necessitated open treatment and one was a conversion to an open shoulder stabilization for multidirectional instability. Arthroscopy, Vol. 4, No. 4, 1988
258
M. J. S K Y H A R E T AL.
FIG. 3. Location of anterosuperior portal (arrow).
FIG. 2. Beach-chair position for performing stabilization. Note medial scapular border at edge of table.
cluded that the best combination of positions to optimize the arthroscopic view and minimize plexus strain was 45 ° forward flexion with 90° abduction, and 45 ° forward flexion with 0° abduction. The position resulting in the least strain was 90° forward flexion and 0° abduction. Among the positions producing the most strain was 30° forward flexion with 70° abduction (3). Of 50 patients in Ellman's series of arthroscopic subacromial decompressions, three patients had transient dorsal digital nerve palsies of the thumb, secondary to arm traction during the procedure (7). Pitman, who used somatosensory evoked potentials to study neuropraxia during shoulder arthroscopy using arm traction, concluded
DISCUSSION Most reports describing the technique of shoulder arthroscopy advise the use of some variation of arm traction while the patient is in the lateral decubitus position (1,2). The use of arm traction for this procedure is not benign. The structure at greatest risk is the brachial plexus (4). In 1985, Paulos reported a nearly 30% incidence of transient parathesias in the upper extremity following shoulder arthroscopy using traction (5). Andrews and Carson described two ulnar and one musculocutaneous transient neuropraxias believed to be related to the use of traction (6). The experience of Klein et al. at the University of Pittsburgh has included an -10% incidence of transient paresthesias and palsies combined (3). For this reason, Klein et al. applied traction (5-25 lbs or 2.25-11.25 kg) to cadaver arms and measured the resultant brachial plexus strain. By relating arm position to plexus strain measurements, they conArthroscopy, VoL 4, No. 4, 1988
FIG. 4. Location of posteroinferior portal (arrow),
SHOULDER A R T H R O S C O P Y: BEACH-CHAIR P O S I T I O N
that the incidence of subclinical transient neuropraxia is high, and probably related to the amount of traction, arm positioning, and joint distention. The musculocutaneous nerve was most frequently involved (8). Is traction really necessary for shoulder arthroscopy? We have had a very positive experience using the beach-chair position without traction on the arm. There are several advantages to this position. Patient positioning is faster and easier. The upright position is much more physiologic in terms of all types of anesthesia techniques. There is no need to reprepare and drape the patient if an open procedure needs to be performed following the arthroscopy, provided sterility has not been broken. When the patient is in the beach-chair position, the capsular anatomy within the glenohumeral joint is not placed in the nonanatomic, stretched-out attitude that occurs with arm traction. This is important for performing arthroscopic capsular reattachment, because of the necessity of obtaining an accurate assessment of glenohumeral ligament laxity in addition to reapproximating tissues under minimal tension. There is more mobility of the arm in the beach-chair position, enabling the assistant to facilitate the field of view by various arm manipulations. A complete view of the entire glenohumeral anatomy is possible with minimal arm manipulation. When the surgeon is performing subacromial decompression, the weight of the arm provides enough downward traction to allow for easy visualization of the space. The ability to manipulate the arm into many different positions with the option of applying variable degrees of intermittent manual traction is useful. In fact, specific arm positioning is critical when attempting arthroscopic rotator cuff repair and stabilization. With the patient's arm at the side, external anatomy is easier to visualize and palpate, especially the coracoid, which is a critical landmark for placement of the anterior portal (9). Access to the anterior aspect of the shoulder is easier when the arm is not suspended within the operative field. The only disadvantage to this position that we have noted is fogging of the camera due to the irrigation solution running down the scope. When the patient is in the beach-chair position, it is necessary to place the arthroscope in the "uphill" position during certain procedures, most notably subacromial decompression. This problem can be limited
259
FIG. 5. Rubber cap placed onto the sheath decreases effluent onto the camera, minimizing fogging.
by minimizing effluent onto the scope during the procedure and solved by newer "fog-free" arthroscopic equipment. The rubber cap from the Acufex disposable cannula system decreases effluent down the scope onto the camera when placed over the arthroscopic sheath (Fig. 5). In summary, placing the patient in the beachchair position for shoulder arthroscopy is simple, prevents potential neurological complications due to traction, and still allows excellent visualization for all types of arthroscopic shoulder procedures. REFERENCES 1. Andrews JR, Carson WG, Ortega K. Arthroscopy of the shoulder: technique and normal anatomy. A m J Sports M e d 1984;12:1-7. 2. Gross RM, Fitzgibbons TC. Shoulder arthroscopy: a modified approach. Arthroscopy 1985; 1:156-9. 3. Klein AH, France JC, Mutschler TA, Fu FH. Measurement of brachial plexus strain in arthroscopy of the shoulder. Arthroscopy 1987;3:45-52. 4. DePalma A. Surgery o f the shoulder. 3rd ed. Philadelphia: JB Lippincott, 1983:35~4. 5. Paulos L. Arthroscopic shoulder decompression: technique and preliminary results. In: North American Arthroscopy Association Annual Meeting, Apt 1985. 6. Andrews JR, Carson WG. Arthroscopic surgery of the shoulder. In: Parisien JS, ed. Arthroscopic surgery. New York: McGraw-Hill, 1988:231--41. 7. Ellman H. Arthroscopic subacromial decompression: analysis of one to three year results. Arthroscopy 1987;3:173-81. 8. Pitman MI. Arthroscopic research. In: Abstracts on sports injuries and rehabilitation, 1%21 Nov 1987, Roosevelt Hotel, New York, NY. 9. Matthews LS, Zarins B, Michae ! RH, et al. Anterior portal selection for shoulder arthroscopy. Arthroscopy 1985;1: 33-9.
Arthroscopy, Vol. 4, No. 4, 1988