the audience that Brett's a West Point guy and I'm an Air Force Academy guy so there's gonna be a little bit of that and that just comes with the territory so I'll apologize in advance I asked him is this supposed to be kind of fireworksy or or just easy and he said he said fireworksy for me easy for you so we'll go for that so there's my disclosures and you know the first thing is is why are we still debating this this has already been won over and over again in favor of the lateral unless you trained at West Point nobody's doing this Brett okay so how did we get here well beach chair was initially preferred because originally we were worried we were gonna have to open the shoulder because we weren't good enough arthroscopically well now we are good enough arthroscopically and so you don't have to be afraid anymore bro you can just keep it arthroscopic and go and you can move over to the lateral position and as we recognize more about instability and especially posterior instability we realize there's tremendous advantage to lateral balance traction and suspension most importantly you counteract the the effects of gravity pulling the head inferiorly right where you need to work so that's where we are from a theoretical standpoint but I'm a data guy as you guys are and certainly Brett is he's far better than I am and so we should get into some of the data so the first thing is you can do a higher quality repair consider this paper this is the moon group data and we know that everything that comes out of the moon group is high quality solid data so it settles the issue right there just when you say moon so in the lateral group what they found was lower anchors more anchors could be done in that group and a longer labral repair right so that's somewhat unavoidable and that's just for anterior the anterior is a lot easier if you're trying to go posterior that's where the beach chair versus lateral conundrum really really gets interesting because the because the beach chair with a posterior instability repair is much harder and so what about the posterior side well let's look at what your colleagues do Brett so if you take it this study by the Colorado folks out there they took a look at a big series of this and they did find no differences in recurrences but remember these are posteriorly unstable patients they don't get recurrences they get pain so a little bit misleading in that regard and this is the important point of this one when they took a look at all of their data it was seven times more common that the surgeons did lateral than beach seven times so you can see who's winning this one so I got to thinking I thought what can I do to explain to Brett that why seven times is an important thing well that's like the ratio of Air Force victories over army and commander-in-chief trophies right there in fact the actual score all-time is Air Force 20 Army 9 so there you go buddy it's a bad one what about safety well this study out of Kesta in 2017 shows us that the axillary nerve is a centimeter closer to the posterior IGHL if it's done in the beach chair position and these authors concluded that if there is an increased risk of axillary nerve injury during posterior inferior labral repair no seriously what about complications let's talk about cerebral desaturation events in some studies these are reported as high as 80% in the beach chair position it's not reported in the lateral position and the average number of many strokes that you give these people's four in the beach chair none in the latter of the cubits position if you take a look at a systematic review of nine studies the average patient numbers in these things for cerebral desaturation events 29% across the board and across studies and this is why you don't follow up your patients at West Point until about 10 days out because CDA's were 25% and patients showed neurocognitive deficits for about 24 hours post-op but they usually resolved over a few days so if you don't bring them back and remember these are army cadets so they probably you don't really know when they're a little bit affected anyway and so when they come back so in conclusion the lateral position gives you better anchor position larger margin of safety from the axillary nerve you're not going to stroke out your patient so there's that and you Brett you can stop feeling embarrassed at parties because you're the only one doing it in the beach chair position thank you very much and good luck

lateral position

beach chair position

arthroscopic techniques

gravity effects

patient outcomes