This is Joe Toro from Ocean County Sports Medicine. I'm going to talk to you about operating room setup for shoulder arthroscopy in the lateral position and I'll talk to you a little bit about why I don't really like ropes and pulleys and why I love my robot. I do have disclosures and a complete list of my disclosures can be found at the AAOS website. So first of all I use a beanbag on the table with the U towards the head and when we move the patient over our goal is to have the top of the shoulder at the top of the beanbag. As far as the legs go we put one pillow on the operating table under the opposite leg and then one pillow between the legs and then we flex the knees until they're stable. The top leg is usually the most stable if it's slightly more flexed and anterior to the bottom leg but sometimes depending on body habitus you may have to change that around and you can certainly tape the legs if necessary just be careful you don't tape tightly over the fibular head and into the perineum. We turn the patient lateral and we decline them posteriorly so that the scapula is perpendicular to the floor and that puts the glenoid parallel to the floor which is what your goal should be. The beanbag when you finish deflating it should be just posterior to the medial border of the scapula so you have full exposure. In the front the beanbag is pulled out from under the non-operative arm and then the bottom of the U acts as your axillary roll. We don't use any other axillary roll. You want to confirm there's no impingement on the chest or breasts and then finally check the radial pulse to make sure that the circulation to the non-operative arm is okay and if you have a good radial pulse you don't need anything else in the way of axillary roll. Of course everybody knows to check the neck. It's important that the neck be completely neutral not pointed towards the operative shoulder where it would cause traction on the non-operative brachial plexus or away from the operative shoulder where you'd have traction on the operative arm brachial plexus. So it needs to be neutral and this is a very important thing to do with the patient lateral. Now what about those ropes and pulleys? They do control abduction and adduction and they do control flexion and extension but they don't control rotation and that traction weight hanging on the end of that pulley just how much force is that hanging weight really producing at the shoulder and I think the robot arms give you a more direct idea. And so I think you realize at this point that I think ropes and pulleys are kind of old-school and the other big disadvantage with ropes and pulleys is there's no control of rotation of the arm which is very helpful for anything you might want to do arthroscopically in the shoulder. I prefer a robot arm which is much easier to adjust. Traction force is precise and easy to see and you have control of rotation as I'll show. So for any assist arm you're going to use you should pre-wrap the hand and forearm with a stockinette and coban and you want to make sure you separate the thumb from the digits. And very importantly when you put the arm into the holder device you want to make sure that the digits are not folded under the post of the holder and it's very easy to do that and then you're going to injure one of those fingers. So the post also needs to be seated right at the base of the thumb so the arm doesn't slip out of the holder. Then of course we wrap it all up and now we're ready to take the arm and put it in this particular arm holder and in this case we just release it hook it up and then what I'm going to do is I'm going to preload the traction on the arm up so that we have enough to add traction if we want later. I'm going to position the arm right where I want it at that point at least for the beginning of my operation. This particular device has a very clear readout of how much traction is on the arm at that point. We normally start with 10 pounds as we go into the glenna joint and we'll increase to 15 pounds when we go in the subacromial space and then as you can see we can lock rotation with this device and that's a very important tool to have in your hands when you're doing both rotator cuff repair and Bankart. Then you can add traction to this as I said typically we're going to go up to about 15 pounds of traction when we go into the subacromial space but again it depends on the body habitus of the patient. I hope that this simple talk on lateral setup for shoulder arthroscopy has been helpful to you. I'd encourage you to try all of the robot assist arms that are out there and find one that you like the best and thank you very much.

shoulder arthroscopy

lateral position

robot arm

operating room setup

Joe Toro