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Techniques

Avoiding Complications in Shoulder Arthroscopy: Pearls for Lateral Decubitus and Beach Chair Positioning

Provencher, CDR Matthew T. MD, MC, USN*; McIntire, Ensign S. BA*; Gaston, Tistia M. PA-C*; Frank, Rachel M. BS; Solomon, CDR Daniel J. MD, MC, USN*

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Techniques in Shoulder and Elbow Surgery: March 2010 - Volume 11 - Issue 1 - p 1-3
doi: 10.1097/BTE.0b013e3181c80acc
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Abstract

The beach chair and lateral decubitus positions are reliable methods to accomplish effective arthroscopic shoulder procedures. The complications associated with each method, and helpful pearls, are discussed below.

LATERAL DECUBITUS POSITION

Advantages

When performing glenohumeral arthroscopy, there are many advantages in using the lateral decubitus position. Perhaps the most beneficial benefit is easy access to all areas of the glenohumeral joint. Instability repairs, superior labral anterior to posterior (SLAP) repairs, and biceps work are easily accomplished in the lateral position. The setup for placing a patient in this position is efficient, and once the operating room staff is familiar with the setup, generally requires less time and is often less involved than the beach chair position. Patient placement in the lateral decubitus position allows for ease of access to—and permits excellent visualization of—the posterior and posteroinferior aspects of the glenohumeral joint without the need to create transrotator cuff portals.1 Specifically, the position more effectively opens the space between the biceps anchor (SLAP region) and the rotator cuff capsule, allowing for ease of suture passage around the glenohumeral joint; this is especially useful when performing SLAP repairs. In addition, subacromial access and visualization, which are excellent in this position, are improved with suspension at 20 to 30 degrees abduction. Furthermore, the lateral decubitus position directs arthroscopic bubbles to float into the subdeltoid space and out of the field of view in the subacromial space. Another advantage of this position is that it permits the surgeon to perform more work with his or her arms at the side (as opposed to having the arms abducted, as occurs when the patient is placed in the beach chair position). Finally, as long as the patient is positioned appropriately and bony prominences are well padded, there is a low risk of complications with the patient placed in this position.

Disadvantages and Complications

In the lateral decubitus position, the orientation of the glenohumeral joint anatomy to that of the surgeon makes it somewhat difficult for (1) training residents, (2) individuals unfamiliar with the orientation, and (3) individuals who are starting with arthroscopic rotator cuff work. The patient usually requires general anesthesia, compared with the beach chair position in which a regional block is typically well tolerated by the patient, although many surgeons use monitored anesthetic care with the patient awake and under regional block. Lateral decubitus positioning requires some type of arm-holding suspension device for proper limb placement, which can create difficulty in manipulating both external and internal rotation, thereby limiting access to some structures (eg, subscapularis tears) and limiting the amount of rotation that the surgeon can perform during the case.

Although necessary for the procedure, suspension itself is potentially responsible for postoperative complications. Specifically, arm suspension has been shown to cause injuries to local peripheral nerves, as well as the brachial plexus and the surrounding soft tissue, and to reduced limb perfusion.2 Other complications associated with the lateral decubitus position include neurovascular injuries, primarily to the musculocutaneous and axillary nerves, particularly during the establishment of the anteroinferior portal.3 Other rare but reported complications include complete airway obstruction4 and spontaneous pneumothorax.5 Finally, a potential for difficulty can occur if and when intraoperative conversion to an open procedure is deemed necessary, mainly with regard to the deltopectoral approach. However, mini-open rotator cuff repairs, open distal clavicle excisions, and open biceps tenodesis (proximal or subpectoral) can be easily performed from this position.

Pearls to Avoid Complications

  • Avoid positions of extreme extension and abduction in the lateral decubitus position to avoid nerve stretch (especially of the musculocutaneous nerve)6
  • Bony prominences, notably the greater trochanter, and the area of the beanbag holder may provide sharp compression points. Additional padding (pillows/foam) in this area is paramount to avoid focal compression (Fig. 1A).
  • A position involving 15 degrees of forward flexion and 45 degrees of abduction has been shown to maximize operative visibility while minimizing brachial plexus strain
  • Avoid excessive strain on the brachial plexus by not using more than 10 pounds of traction
  • Neutral neck positioning with careful attention to the patient's normal cervical kyphosis is crucial to avoid cervical spine issues
  • Use special head and ear donuts to avoid pressure injury on the periauricular structures (Fig. 1B).
F1-1
FIGURE 1.:
Intraoperative photograph of the lateral decubitus position. A, The beanbag has sharp corners at the ends once inflated, thus adequate padding (ie, pillow) is utilized at the sharp transition points. B, A gel donut or equivalent is placed under the head is important to prevent periauricular nerve compression injuries.

BEACH CHAIR POSITION (ARM FREE)

Advantages

The beach chair position with the arm free allows for ease of anatomic orientation. In this position, arthroscopic visualization of the anterior, inferior, and superior glenohumeral structures, along with the subacromial space, is excellent. Patient placement is easily accomplished as no additional equipment is required, and a standard operating room table can easily adjust to the beach chair position. The beach chair position with the arm free is the best option for open shoulder surgery, especially with regard to the deltopectoral approach, and for arthroplasty cases. Rotational control of the upper extremity in this position is optimal, particularly in cases of subscapularis tear repair and specific cases of rotator cuff tear repair (very posterior: infraspinatus) and for precise positioning during cases involving rotator interval closure. In this position, no traction is needed, which makes set-up easier and avoids the complication of brachial plexus strain, commonly seen in the lateral decubitus position.7

Disadvantages

A major drawback of the beach chair position with the arm free is that the surgeon's arms are abducted at the glenohumeral joint for the majority of the case. This increases the fatigue factor, generally not seen when the patient is placed in the lateral decubitus position. It is also difficult to provide good distraction without an assistant, thus an assistant is typically required during the entire case. Well-positioned drapes are also needed to keep the arm in the appropriate position during the entire case. Finally, the beach chair position with the arm free provides less visualization of the posterior and posteroinferior aspects of the glenohumeral joint.

BEACH CHAIR POSITION (ARM MOUNTED)

Advantages

The beach chair position with the arm mounted allows for precise control of arm rotation during the case and eliminates the need for an assistant to manipulate the arm.7 This position also allows for traction in multiple planes, especially inferior, when performing subacromial work. It is important to note that not all arthroscopic shoulder cases require precise positioning and traction afforded by the arm-mounted devices.

Disadvantages

A major disadvantage of the beach chair arm position with the arm mounted is a potentially longer operating room setup time. Sterility of the setup equipment can be an issue. To maintain sterility of the various devices, extra drapes and multiple attachments are required. A nitrogen supply is also necessary for the pneumatic arm holders. Overall, these added attachments may add time and cost to the case.

Complications Associated With the Beach Chair Position

Similar to the lateral decubitus position, several complications can occur when the beach chair position is used. Specifically, after arthroscopic surgery in the beach chair position, nerve injury (hypoglossal, cervical plexus),8 vasovagal episodes, visual loss and ophthalmoplegia, superficial cervical plexus injury, and cerebral ischemia have been described. Hypotensive episodes and subsequent ischemia-related problems, mainly in obese individuals with a larger abdominal bulk, have been reported to occur in more than 20% of patients undergoing arthroscopy in this position.9 Posterior cerebral circulation can be compromised in this position because of hyperextension and rotation of the neck/head, which can decrease blood flow through the vertebral arteries.10

Pearls to Avoid Complications

  • Augment perioperative medications with a β-blocker (eg, metoprolol) to decrease the incidence of hypotensive and bradycardic events
  • Consider placement of blood pressure cuff at the level of heart instead of the calf; if not possible, interpret calf pressure relative to heart-level pressure to avoid iatrogenic cerebral hypoperfusion.10
  • Position the buttocks up against the beach chair bed to ensure that a pressure injury (ulcer) does not occur (Fig. 2A).
  • Avoid excessive external rotation at the side to avoid brachial plexus strain.
  • Avoid elbow flexion beyond 90 degrees to prevent distal upper extremity nerve compression (ulnar and medial nerves)
  • Position the head in a neutral position in both the coronal and axial planes to decrease the risk of hypovascular incidents (Fig. 2B).
  • Use a padded v-foam leg holder to avoid compression and irritation of the buttock and upper leg
  • Ensure proper padding at the level of the knee to avoid irritation of the peroneal nerve.
F2-1
FIGURE 2.:
Intraoperative photograph of the beach chair position. A, The buttocks should be placed flush against the beach chair bed, and rechecked once the bed is in an up position to ensure that pressure sores do not result. B, The head should be placed in neutral position in both the coronal and sagittal planes to decrease the possibility of hypovascular complications.

GENERAL PEARLS AND COMPLICATIONS

When performing shoulder arthroscopy in any of the arrangements described above, great care must be taken to properly position the patient to avoid complications (Table 1).

T1-1
TABLE 1:
Complications Associated With the Lateral Decubitus and Beach Chair Positions

Both the lateral decubitus and beach chair positions can lead to neurological problems. Brachial plexus strain is the most common complication related to positioning the shoulder for arthroscopic shoulder. It is important to avoid excessive traction; subclinical neuropraxia is higher than recognized. The zone of safety for the axillary nerve during capsulolabral repair in the inferior aspect of the shoulder joint is increased by placing the shoulder in abduction, external rotation, and perpendicular traction.

REFERENCES

1. Provencher MT, Romeo AA, Solomon DJ, et al. Arthroscopic preparation of the posterior and posteroinferior glenoid labrum. Orthopedics. 2007;30:904–905.
2. Hennrikus WL, Mapes RC, Bratton MW, et al. Lateral traction during shoulder arthroscopy: its effect on tissue perfusion measured by pulse oximetry. Am J Sports Med. 1995;23:444–446.
3. Gelber PE, Reina F, Caceres E, et al. A comparison of risk between the lateral decubitus and the beach-chair position when establishing an anteroinferior shoulder portal: a cadaveric study. Arthroscopy. 2007;23:522–528.
4. Hynson JM, Tung A, Guevara JE, et al. Complete airway obstruction during arthroscopic shoulder surgery. Anesth Analg. 1993;76:875–878.
5. Dietzel DP, Ciullo JV. Spontaneous pneumothorax after shoulder arthroscopy: a report of four cases. Arthroscopy. 1996;12:99–102.
6. Weber SC, Abrams JS, Nottage WM. Complications associated with arthroscopic shoulder surgery. Arthroscopy. 2002;18(2 suppl 1):88–95.
7. Skyhar MJ, Altchek DW, Warren RF, et al. Shoulder arthroscopy with the patient in the beach-chair position. Arthroscopy. 1988;4:256–259.
8. Park TS, Kim YS. Neuropraxia of the cutaneous nerve of the cervical plexus after shoulder arthroscopy. Arthroscopy. 2005;21:631.
9. Peruto C, Ciccotti M, Cohen S. Shoulder arthroscopy positioning: lateral decubitus versus beach chair. Arthroscopy. 2009;25:891–896.
10. Papadonikolakis A, Wiesler ER, Olympio MA, et al. Avoiding catastrophic complications of stroke and death related to shoulder surgery in the sitting position. Arthroscopy. 2008;24:481–482.
Keywords:

lateral decubitus; beach chair; shoulder arthroscopy; shoulder positioning; surgery

© 2010 Lippincott Williams & Wilkins, Inc.