So beach chair positioning, tricks to make it simple. So that's what we're going to be talking about today. And I just want to thank, you know, Pat Denard for inviting me to this course to speak. I think it's definitely an honor to be asked to do this. When I was a resident, I used to come to the OLC to help out on the weekends for these courses. And it was incredibly beneficial to my training to be able to see, you know, the people that were, or the surgeons that were the best arthroscopists in the world. I think it definitely gave me a ton of great information and training and getting exposed to a lot of different things, even early on in my residency. So, and I always thought when I was helping out during those courses that it would be pretty cool to be a faculty on the other side teaching. So awesome to come full circle, come back to the OLC and great coming out of the pandemic to be able to do these meetings again. So thank you again for having me and I'm honored to be here to speak today. So tricks to making beach chair simple. So I always think it's great to kind of tell your story a little bit when you give these talks, even if it's a short talk. So when I trained, I trained in South Carolina with Dr. Hawkins and so much of what we do, especially when we first come out as a product of where we train. So most of the surgeons that I trained with in South Carolina had trained under Dr. Hawkins in some regard, and we scoped laterally, 99% of the time. And my first 200 shoulder scopes that I did, and those were all in my residency, were lateral positioning. So that's all I knew. I'd never seen anything other than lateral positioning. So I thought that that's really just how you scope shoulders. I knew that surgeons did scope beach chair, but I had never seen one or experienced it. And so when I was coming out in my fellowships, I was pretty set that that's how I was gonna do things. So I then traveled to Pittsburgh to do my first fellowship and then Lyon, France to do my second fellowship. And lo and behold, they did everything in beach chair position. And really when I was doing that as a fellow, it came naturally, especially doing rotator cuff work. It was simpler. It was a simpler setup. The anatomy was positioned in a way that you understood better. So I decided pretty quickly, probably halfway through my fellowship in Pittsburgh, that I was gonna at least do all my rotator cuffs in a beach chair position. And then when I went to France, it was the same thing. And we did nothing but shoulder surgery in France with Dr. Walsh. And they did everything in the beach chair position, labor work and beach and cuffs. And so I decided coming out into practice, that's how I was gonna do my rotator cuffs. And I haven't looked back since. I think that it's helped simplify my practice, helped simplify my setup for a lot of different reasons. So, you're always trying to simplify things in your practice. There's so many complexities that we can't control for. So the things that we can control, we wanna simplify them. Albert Einstein said, you should make everything as simple as possible, but no simpler. And I agree with that 100%. And so by doing your rotator cuffs in a beach chair position, which is the bulk of the majority of our shoulder practice, arthroscopy practices, rotator cuffs. I think for most surgeons, it's probably 10 to one, in terms of the number of cuffs you do in terms of labor repairs, if you really look at your numbers. And then you add in all the open shoulder surgery that you do. And it allows for you to have the same setup for probably 90% of your cases. Whereas if you're going lateral, then you're flipping back and forth between the positioning when you're doing open and arthroscopic surgery. And so, for me, probably out of all my shoulder cases, 65% are arthroscopic, but the other 35% are open arthroplasty cases or fracture work. And so I think that by having your scope positioning be in a position where it's similar to most of your open work, it really helps with your team and setting everything up. And again, going back to the anatomy, I think human beings have evolved to be in an upright position. And by having your shoulder set up in this way, it definitely helps with understanding the anatomy for sure. And we also evolved to being a little bit heavier as a species over the last 50 years. And so getting someone that's 350 pounds plus in a lateral position is quite difficult. Whereas in a beach chair position, it's not easy, but it's definitely easier. So, these are two quick videos that we're gonna go over talking about simple tricks for making it as simple or keeping the positioning as simple as possible. I think keys for me are getting the patient high on the bed or getting them set upright to probably, you can't get most people fully flexed all the way up, but getting them flexed up to at least 60, 70 degrees from the floor. I think having a nice table, we use the Smith and Nephew T-Max bed where you can slide the back left or right, which helps expose the entire shoulder blade. So if you have to do something like a latissimus transfer or a low trap transfer, you can do that from this bed easily. I also think that, you know, keeping your mean arterial pressure below 70, which you can do very safely in a beach chair position, helps with visualization. I think that's a knock on beach chairs. You can't get the blood pressure as low, but if you look at the literature, there's no increased number of events or ischemic events due to beach chair positioning compared to lateral positioning, at least that I know of. So I think it's safe to have the blood pressure low enough to do the work that you need to do. You can put the arm in space wherever you want when you have a pneumatic arm holder, we use the Spyder, but there's multiple other companies out there that have these, and it's very easy to move the arm around in space in a beach chair to internally, externally rotate, abduct, internally rotate, you know, pull the humerus laterally if you do have to do, for me, if I have to do a combo case with a cuff and label work, it's very simple to do that. If I'm doing really complex label work, I still go lateral, but for simple label repairs, it's very simple to do in a beach chair position. And J.P. Warner wrote that up showing that that's perfectly acceptable and you can get great outcomes that way. So again, these two quick videos are shot from us in the operating room, and we'll go over, you know, how we set things up and how we keep the setup as simple as possible so that you can worry about how to fix your rotator cuff. Thank you very much and enjoy the videos. All right, so my preferred method for scoping shoulders for rotator cuffs is beach chair. I think it's easier, it's an easier setup, it's easier in terms of just, you know, the anatomy is more normal, I would say, because you're upright. And so some of the keys we have found about the beach chair positioning is a lot of it's, you know, the bed that you use. So we use the Smith & Nephew T-Mac bed, and the nice part about it is that it's got a sliding mechanism in the back that frees everything up in the scapula. So I think that that helps a lot to have a bed where you can remove the armboard in the back. I also think when you're positioning them before you bring them up, you want them as high up on the bed as possible so that you basically have the whole posterior of their shoulder exposed. When you sit them up, you reset all three of these dials here to make sure that their head is in a good position and that there's no tension on their neck, right? So that's main things. Then we've got a prep and drinker, pretty standard. And then another key to beach chair, I think that, you know, if you look at the literature on beach chair, yes, you do get a decreased perfusion by being in a seated position versus being lateral. However, we regularly keep our mean arterial pressure less than 70 in a beach chair position. I think that helps a ton with visualization. So those are some of the main things that we see. And then we'll, in one second, we'll get this prep and drink and we'll show you how we position the arm. So now we've got our shoulder draped, now we've got our shoulder draped out and in a nice position here. So I like to mark off posterior aspect of the acromion, lateral acromion, clavicle here, the visors, AC joint, and then antilaterals here, posterior portal, about one, one and a half centimeters in. And then once I've got all that marked out, then we bring the arm out on the traction, about probably 30, 45 degrees abducted and then down with a decent amount of traction. It helps pull things away. Now, if you're doing intra-articular work, each chair, which you can, there are plenty of surgeons out there that do a lot of labral paired beach chair. I still prefer to do those laterally, but you still, I have, I've done combo cases, you can do a beach chair, no problem, but basically you just bring your arm down here and then if you just have your assistant and PA pull laterally like this, you get the, you basically get the humeral head off the glenoid and you can do basically whatever you need to do intra-articular to a beach chair position. So if you can do labral work, and J.P. Warner even wrote that up a couple of years ago in the Ellen Journal, that's perfectly acceptable to do labral work in a beach chair position. I think it's just a matter of preference. So, but it costs 100% of the time that we go beach chair and it's worked great for us. So thank you very much.

beach chair position

shoulder surgeries

rotator cuff repairs

anatomy visualization

arthroscopic and open shoulder surgeries