Good evening, my name is Travis Decker, I'm an orthopedic sports surgeon for the United States Air Force down at Eglin Air Force Base in the panhandle of Florida. I'll be discussing the lateral decutis position and how it can be a tool for the global management of the shoulder, specifically with arthroscopic procedures. So although I have no relevant disclosures, this presentation is full of recommendations based off of my own personal experiences and my training. Things that have gone well for me as I've started my practice, specifically utilizing the lateral decutis position for a variety of cases, I've been very lucky to train under some very gifted mentors. Dr. Hackett has taken me through a lot of tips and tricks to be successful, but some of these tips that I've learned that I'll be sharing have been when I've had to learn lessons the hard way. In addition, parts of this presentation were gifted to me by Dr. Hackett, specifically from both he and his team, so I have great appreciation as that mentorship continues to just bless me in my practice and the care of our patients. So shoulder positioning, why does it matter? Well there are clearly regional biases and training biases as to preferred shoulder position with excellent outcomes in both positions when they're performed well. So the goal of this talk is not to convince anyone to do the lateral position, but instead to give the surgeon another tool if they desire to utilize lateral positioning for specific cases and how to set yourself up for success to do so. There are multiple clinical studies and outcome studies and systematic reviews that have shown excellent return to activities and outcomes when utilizing the B-share lateral decutis position. There is some conflicting evidence, however, that sometimes the lateral decutis position can actually decrease recurrence rates when used for instability procedures. Why is this possible? Well, surgeons have been shown that there are technical differences when they approach certain procedures in the lateral decutis versus that of the B-share position. Surgeons that utilize the lateral decutis position specifically for that of instability procedures have noted that they identify longer and more extensive tears compared to that of the B-share position. And in addition, they utilize a 6 o'clock anchor more often. And so when they're identifying larger tears and utilizing 6 o'clock anchors, oftentimes these repair constructs can be more extensive with more fixation points compared to that of the B-share position. In addition, also why it matters is that there's different neurovascular structures at risk based off of the position that you utilize. And so understanding where the neurovascular anatomy is when you have the patient either in the B-share or lateral decutis position is essential in order to keep the patient safe. So speaking of regional biases, there's a clear West Coast bias that was popularized by Dr. Snyder out of SCOE that they utilized the lateral decutis position for all arthroscopic procedures. And then there's other institutes to include KJARC as well as Dr. Burkhart, where all of these institutions have trained hundreds of surgeons that utilize the lateral decutis position for all arthroscopic shoulder procedures. Well, then there's the powerhouse of the Northeast with HSS where you have Dr. Warren, Dr. Hannafin that have popularized the B-share position with excellent outcomes with doing similar procedures in the B-share position. So at the end of the day, what is really best? Well, the realistic answer is do what's best in your hands. And by doing so, you're giving yourself and your patients the best shot at success. But the purpose of this talk is really to highlight the lateral decutis position and small pearls on the positioning itself and how it can facilitate visualization in working and improving working space to increase efficiency in the operating room. So there are clear advantages to using the lateral decutis position, the main of which is improved visualization as well as, and as a result, increased working room. But there's also the benefit of having increased cerebral perfusion as the patient is in the lateral decutis position compared to the B-share position just based off of gravity and where the position is set up. In addition, a military surgeon like myself, I often utilize the B-share position for rotator cuff pathology and I use the lateral decutis position for instability procedures. If you opt to go for the lateral decutis position for both, it can facilitate a single setup which can improve efficiency and just make the procedure a much more simple task and set up a simple task for your team. There are disadvantages that there are risks for traction injuries. There have been case reports of brachial plexus palsies and neuropraxies. And so ensuring that you're utilizing the right weight, which has been described between 10 and 15 pounds for traction, and not exceeding that can prevent that. And in addition, based off of the patient positioning, it can be difficult to switch to an open approach if this is required. So if required to do so, it may require multiple positionings and re-prepping and draping of the patient. Lastly, the cephalic vein, based off of where the arm is positioned, can be at risk for portal placement. And so it's just something to be aware of as you're going through. And so one thing that I'd like to provide is a bit of a test of what are the tips and tricks of the lateral decutis positioning. And then as well as portal placement, it's all about visualization and how do you first start that is how you set the patient up. So it begins right as you get the patient on the table. So my hope is things that I've learned through my ups and downs and successes and failures, this is somewhat of the cookbook recipe that I've come up with in optimizing visualization and then working space, which has then improved my efficiency over time in the operating room. So step one, as soon as I walk in the room and we flip the patient in the lateral position, I always ensure that they're the most superior aspect of the bed. You have to know your shoulder jig system. There are new systems that allow for multiple angles and areas of traction. They have old fashioned fishing poles, lateral traction, ropes and pulleys, but also they have different mnemonic lateral positioners, such as the spider arm positioner. So knowing exactly what your system is, where it's positioned can dictate where and how much traction you can get on the patient based off of where they're laying down in the bed. But one thing that does help is that especially in taller patients is pulling them up to the top of the bed can ensure that you don't run out of room when you're trying to pull traction on them. This is within surgical procedures, ensuring that the patient is well padded. The patient will be lying on their side for quite some time just during the operation. And so as a result, you want to ensure that all nerve vascular structures are well padded, specifically the common perineal nerve, the down leg, want to ensure that it's free or that it's well padded to prevent any common perineal nerve neuropraxia. In addition, securing the patient in the optimal position, I use these kidney rests. This can be done with a belt, can be done with tape, can be done with co-band, but ensuring that you like the positioning of the patient based off of what you're doing, whether or not you're doing instability and putting them in a straight lateral position, or if you're working on rotator cuff pathology where you want to have them slightly in a sloppy lateral for possible biceps tenodesis at a later time point. You have to pick and choose, but knowing where the position of the body is can help facilitate how quickly you're able to do certain aspects of the procedure. Next, because of the patient positioning in larger patients, the assistant that is prepping the arm may need help, may need an extra set of hands. Larger patients can fatigue your assistant. So just being aware and ensuring that the patient is set up in a sterile fashion. I then seal the drapes with Ioban dressing. So there have been times when I have not done this, and there can be water that seeps through the drapes, and so Ioban has been a good, sturdy way for me to seal the drapes and prevent further runoff. It also helps facilitate ensuring that the arthroscopic fluid runs off into the bags. There are different degrees of abduction that can facilitate different areas of visualization. Thirty degrees has been shown to be the optimal position for joint distraction, while also optimizing the viewing space of the subacromial space. This allows for that optimal intra- and extra-articular work. There can be varying degrees of abduction, though, that can facilitate viewing, specifically that of instability. If you're looking at the posterior capsule by increasing abduction, it does facilitate visualization but does shut down different areas. So sometimes having an adjustable arm holder that can change positions can truly facilitate what you're viewing and how you're viewing it. Next I'd like to go through a couple of specific cases in order to show how portals can really change what you do. And so for my instability procedures, these are my main four working portals of an anterior superior portal, a mid-glenoid portal, a standard posterior viewing portal, and then turning into a working portal, and lastly, a 7 o'clock percutaneous portal. This has been described as being four centimeters directly off the posterior lateral edge of the acromion. This is in parallel with the axis of the clavicle. This allows for more perpendicular access to the joint to facilitate anchor placement that won't skive. And I'll show you how I do this. Starting from a standard posterior viewing portal, I make a high anterior superior portal, which will become my viewing portal, right off the biceps. This also allows for working low at the beginning of the case for probing and diagnostic aspects of the arthroscopy, but it as well can be utilized for labral elevation and freeing of the soft tissue. I then place that mid-glenoid portal. I do use a self-retraining cannula, and this is placed just above the subscapularis. You can see that just beneath the foot of the cannula there. This will be a main working portal that I utilize, and then flip my eyes to the anterior superior portal in order to visualize the labrum. This was a posterior labral tear, which had a crack beginning at around the 6-37 o'clock position, and I was able to probe this through my standard posterior portal. And as I had discussed, a 7-o'clock percutaneous portal, if you hone in on where that percutaneous needle is, you can see the trajectory to the glenoid is just vastly different. And so the standard posterior portal is that 2 centimeters off the posterior lateral edge of the acromion, but then although the entry point is similar within the joint, the angle to drilling of the glenoid is much more perpendicular and thus has a much lower rate of skiving off or causing any chondral damage or penetration to the joint. This was a percutaneous, this is a percutaneous portal that I utilize in order to place anchors starting down low and then coming up in a more superior fashion. I'm able to utilize this up until towards the top. If you need to, you can use newer technology, which have these curve guides with the bend of the curve annotated by this laser line here. And by doing so, you can use more traditional portals without having to use percutaneous portals in order to place these different guides. They have to be soft anchors in order to be utilized with these curve guides, but it does give the surgeon another tool when dealing with instability type procedures. And then this is the final construct of a standard three-anchor repair. And next I'd like to highlight rotator cuff. This was given to me by Dr. Hackett and his team out in Vail. In a similar fashion, these are similar steps to any standard rotator cuff, but being particular about where and how you make your portals can set you up for success with increasing your visualization. You begin with your standard posterior viewing portal, which is two centimeters medial, as well as inferior to the posterior lateral edge of the acromion. And then utilizing a 50-yard line portal approximately four centimeters lateral to the lateral edge of the acromion, and then a standard anterior superior working portal. When the interarticular portion of the case is completed, you then jump up to the subacromial space. As you can see, the camera is rotated such that it's in a more anatomic or familiar position. For those that do utilize the beach chair with the acromion being oriented in a superior fashion, this allows for a complete persectomy for further visualization of the footprint and whatever pathology you may be encountering. And then lastly, after you've cleared the footprint, is the insertion of the anchors. So you're placing a percutaneous portal just adjacent to the acromion. Then look at the angle of Dr. Hackett's hand here as he is placing a standard suture bridge technique for a crescent-type rotator cuff tear. Having an understanding of where the arm is in space, as well as where the orientation of the joint is, can prevent anchor penetration of the joint, as well as optimizing where the anchors are placed. And then through that subacromial lateral working portal, a standard lateral anchors can be utilized for the suture bridge. And then lastly, one last point I'd like to highlight, and one thing that I've shown throughout these cases and through these highlights, is there's lots of really cool technology out there that can help optimize your experience in viewing and then working environment within the lateral decubitus position. So utilize these self-retaining cannulas, flexible guides, antegrade lasso and suture passers can help improve your efficiency as well as just increase your working space when in the lateral decubitus position. So I hope that through this presentation, I was able to impart some of the tips and tricks of things that I've learned early on in my practice, as well as provide a little bit of a cookbook recipe for success on how to set your patients up if and such you desire to proceed with pursuing lateral decubitus position for any type of shoulder arthroscopic procedure. Thank you for your time.

lateral decubitus position

shoulder arthroscopic procedures

surgeon's preference

beach chair position

improved visualization