This talk is on Introduction to Beach Chair Position for Arthroscopic Shoulder Surgery. Given the title, it'll have some basic elements. These are my disclosures. I'll try to address these areas. The group at Hospital for Special Surgery studied this in the late 80s to describe the beach chair position as an alternative to lateral decubitus. They looked at multiple procedures in patients for the optimal positioning, and they found some advantages. Presumed anatomic position, they felt it was faster. It allowed access and easy conversion to open surgery, which was more relevant at that time. Let's go into the positioning with the beanbag. You must make the shoulder lateral to the table edge. These are pictures that Russ Warren sent to me about a dozen years ago. You certainly can achieve the proper positioning to do an arthroscopic shoulder surgery in beach chair. There are adaptations. This is of a device that mirrors what was used at Columbia where I trained. Just to show you, this is something Hirofukura used for his shoulder surgeries. Soon, commercial devices were developed specifically designed for this function. This is one of the earliest designs. The manufacturers of tables made modifications, and then other devices came out that allowed for both arthroscopic and open surgery quite easily. It became apparent that positioning the arm would be important and being able to control that positioning. Devices were developed for this. This is the first device, and you can position the arm securely. But other devices were developed and there are now a few on the market. The goal is to maintain the arm in a proper position for the techniques being used. Here you have the arm in neutral position, and here a distal traction. The same thing would be seen in the subacromial space with an opening up. I'll go through the preparation. Beach chair allows for sedation, but you can also use general anesthesia. About 70 degrees, the patient is seated at and you support the back and head well, can account for any type of body habitus. You've got a pad all down surfaces, including the contralateral arm. A pillow for the legs is helpful or you can adjust the table. You want to make sure the legs are secure. SEDs and body warmer are essential. You rotate the table 45 degrees away from where anesthesia is to give more room. Then you can prep and drape. What you end up, for me, is to be able to have a surgeon and a PA in position that can switch because you sometimes need to view from anterior or posterior. What's the operative setup look like? The circulating nurse can prepare the skin. A simple downsheet. You include the arm, one split in this direction and a second split, and that's it. You can place instruments over the patient as well as behind where you're standing, and then your surgical team has a position to be able to be in, as well as your scrub tech. I do like the two Mayo stands and I learned this when I visited Laurel LaFosse. Not just one over the thighs, but one behind the surgeon, and you can place instruments that you need readily available for the procedure, as you can see here. The surgical tech can be behind you or at the foot of the bed. Obviously, adjust the table height to your comfort. Place the TV screen so that you can see it comfortably. You want to make sure that it's in an optimal position. I like using foot pedals. I'm doing enough with my hands and I can manage more things that way, but they're typically positioned below the posterior portal where you're standing most of the time. Just one example of what you can do in the beach chair or other positions such as with fluoroscopy. Here I'm removing a calcium, and there you can see the imaging being able to come in. I'm going to show some case examples. I like the beach chair position because when you're doing the exam under anesthesia, you're in a more anatomic setup. Here's the sulcus sign testing for posterior translation and anterior translation. Orthoscopically, you can show sublocation or dislocation of humeral head viewing from posterior in this right shoulder, or internal impingement also viewing from posterior in this right shoulder. There've been some reports about glenohumeral repair procedures that are not as easily done in the beach chair position. I haven't found that to be the case. Some examples here such as an ALPSO lesion, but it's also bony bank hearts and anything in the front for me. You can mobilize the tissue well, translate it superior and laterally onto the rim, get a nice secure repair. Same thing goes for the variations of slack lesions and repair, as well as the posterior labrum, and haggle lesions. If you're replacing sutures or implants around the glenoid, for me, I can do this in the beach chair position including capsular plication. Also in the glenohumeral joint, I prefer to do subscapularis repairs. Anchors can be placed, sutures are passed, and you get a good secure repair. Outside the glenohumeral joint, in the superpectral region, you can do a biceps tenodesis with a socket or with an anchor. Then cuff repairs viewing from inside the joint and then subacromial space and the lateral portal view with anchor placement and repair. Easily achievable in the beach chair position, as well as some other less frequently done procedures, including suprascapular nerve release. Adverse events can occur. This can happen also in lateral decubitus position. It's important to know what they are and protect against them. In conclusion, beach chair and lateral decubitus are both reliable, have unique steps and issues, and both allow access for procedures and repairs. I did note a positioner for lateral in my OR, but it doesn't get used much. To me, it's less the position and more the positioner, and I believe anybody can learn to do either well. Be routine and consistent and avoid variables. This is my current setup taking last month in a teaching environment in the hospital and then in ASC. The only thing that's changed is the mask for COVID. Beach chair works well for me. One final thought, how you prepare is as important as how you repair, or if you prepare well, you can repair well. Whatever position you like to use, you can achieve your goals for your patients at shoulder arthroscopy. Thank you.

beach chair position

arthroscopic shoulder surgery

surgical preparation

shoulder procedures

Hospital for Special Surgery