I knew JT was going to have to drop a little bit of napalm as he usually does from 30,000 feet and then flies away. So not so fast, JT. Lateral position, I think beach chair works also. Hopefully I can convince you otherwise. So I do have a couple disclosures. JT tried to tell us, well, it's got to be the position, and not so fast. It's not just about the position. The bottom line, I would think that the passion, like many things, the passion is often inversely proportional to the amount of data to support that position. But there's very little data to suggest superiority of one position versus another. You can do a good or a crappy repair in either position. Why do we even have two positions? Well, I think there is a little bit of regional training bias. I did residency lateral decubitus. I did beach chair and fellowship and stuck with it. The earlier arthroscopy certainly was beach chair, and then there's been a lot of development recently in lateral decubitus position. Some like to call it a modern technique. I'm not sure about that. We have two positions because they both work well. There are advantages to the beach chair position. It's easily correlated in anatomy, not just for the surgeon, but also for the assistants. You can easily address all pathology. You don't need to flip them to fix the cuff or something like that. You can easily convert to open procedures. You can move the arm in space. You can do this under regional and Mac, which was great, especially during COVID. There are disadvantages, though. Certainly, there's a difficulty accessing that superior portal and holding the camera vertically. You don't get as much access in that inferior axillary pouch. As he mentioned, there is risk of cerebral edema. The opposite of that, of course, the advantages of lateral decubitus. You can see really well, especially inferiorly. It's easy to use that superior portal for your camera and better cerebral blood flow. Disadvantages, again, the corollary. I would say that there is a little bit of increased risk shown of axillary nerve and musculocutaneous nerve in this position in a few studies. Again, this is pretty rare in both positions. I think we can call this a draw, JT. This debate has been raging for years. I think the Rachel Frank article in 2014 really added a lot of fuel to the fire. She pulled 3,600 shoulders. These are studies starting back in 1990 in the literature. A failure regression showed a failure rate of 3.6% for beach chair, 2.3% for lateral decubitus, but it was statistically significant. These include shirt tax. Again, you exclude those, it's still insignificant, but there's no analysis based upon the years of publication. A resident of mine and a few others have also shown that there is a temporal bias and instability reporting papers. We really found that we call it the Gao line now, but the year 2000 may represent a turning point for arthroscopic stabilization. This is, again, from the Frank paper here in the lower left. You can see the methodologic scores prior to 2000 were very poor. Again, I think we may want to repeat that analysis, excluding those early papers. The Moon group, as JT mentioned, they did show that more anchors were placed in the lateral decubitus versus beach chair positions. Certainly the outcomes are where it's important, and the analysis is still early, but it does not look like it's going to be significant, and we'll have to wait for that. How do we judge the anchor position? Well, actually, a recent study showed that the beach chair may be a little bit more accurate. So maybe the lateral decubitus folks are thinking they're getting it more accurately, but may not be able to see it as well as in the beach chair posterior view. Posteriors? Well, actually, there's even less data here. This was a paper meta-analysis performed by Rachel Frank, similarly, and she found no difference in recurrence for posteriors, no difference in return to support. But the conclusion, long-term RCTs are required comparing these two. Another study, also same year, 2019, over 1,000 patients, they actually found a trend towards lower recurrence rate, higher outcomes, sorry, higher returns to pre-injury level for beach chair compared to lateral decubitus. But again, they concluded it's got to be the position, right? Still larger RCTs are needed. We do not need an RCT to answer this question. Both positions work very well. Can you address all the pathology? Well, I think you can, and you have to be able to address it all at that sitting. Why do I like beach chair? Well, I can correlate my exam with my exam in the office, my EUA. I also like to perform an arthroscopic exam on their anesthesia. This allows me to titrate my capsulography and be able to make sure I have a quality of repair both anteriorly and posteriorly. What can't you do? Well, you can do everything. You can fix a Hagel. Certainly, you need a 70-degree. It certainly helps you. You can fix a Regal. You may not have that great inferior access that you have, but certainly, you can get a good distraction. You can fix a posterior as well. Don't believe the hype. You don't need to do this in a lateral decubitus position. You can do this in a beach chair position as well. What are the pearls? Well, certainly, a spider arm positioner can help. Use of axillary roll can also be used in the beach chair position in addition to the lateral decubitus position. You need to be precise with portal placement. Similar to Ivan, I really like to crest over that subscap, be able to lower my intra-inferior portal to get really low on the intra-inferior glenoid. Can I get to 6 o'clock? Well, these are actually videos from my surgery. I flipped them 90 degrees. It's not an optical illusion, but this was done in the beach chair position. I just flipped them for you, JT. Can you get to 6 o'clock? I think I can. Does it matter? Well, I thought you were going to actually talk about this study that we did in the lab that shows that it does make a difference, but we don't know clinically if this makes a difference in getting to 6 o'clock. So bottom line, beach chair equals lateral decubitus position. Let's stop the position shaming. You can get there well in either position. Neither is superior in general. One may be superior for you. Again, you can do a good repair or a crappy repair in either position. I wish we could move on from this debate and focus on some more important factors. Thank you.

beach chair position

lateral decubitus position

shoulder repairs

recurrence rates

portal placement