Lateral Decubitus Positioning For Shoulder Arthroscopy

Abstract

Background:

Lateral decubitus positioning is a frequently employed technique to perform shoulder arthroscopy. Proper patient positioning and equipment setup is crucial to ensure a safe and efficient surgery.

Indications:

The common indications for performing a shoulder arthroscopy in the lateral decubitus position include anterior shoulder stabilization, posterior shoulder stabilization, superior labrum anterior to posterior (SLAP) repair, diagnostic arthroscopy for internal impingement, and arthroscopic capsular release for adhesive capsulitis.

Technique Description:

After undergoing general endotracheal anesthesia in the supine position on a standard operating room table, the patient is rotated into the lateral decubitus position with the operative arm facing upward. The patient’s head is supported with a pillow to ensure a neutral position. The nonoperative arm is flexed forward and rests on a padded arm board. The sides of a bean bag are applied to the patient’s torso to maintain the lateral decubitus position, and the bean bag is deflated to remain rigid. An axillary roll is placed under the axilla, and foam pads are placed below the “down leg” and between both legs. A commercial arm jack is positioned on the anterior, proximal side of the operating room table to allow for 20° of shoulder abduction, which maximizes the glenohumeral joint space.

Results:

Advantages of the lateral decubitus position over the beach chair position include improved access to the anterior, inferior, and posterior glenoid; more ergonomic positioning for the operating surgeon; lower risk for patient cerebral hypoperfusion; and reduced rates of recurrent instability following arthroscopic stabilization in comparison to procedures performed in the beach chair position. Disadvantages of the lateral decubitus position include risk of traction-related neurovascular injury, requirement of an arm suspension device, and increased difficulty in rotating the shoulder intraoperatively.

Discussion/Conclusion:

Lateral decubitus positioning is commonly used to achieve a circumferential view of the glenohumeral joint in shoulder arthroscopy. This surgical position yields several advantages for the operating surgeon and has been shown to be associated with improved clinical outcomes after shoulder instability surgery.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

In this brief video, we will discuss lateral decubitus positioning for shoulder arthroscopy, our indications, and our preferred technique of setup.

Author disclosures are as listed.

Our common indications for performing shoulder arthroscopy in the lateral decubitus position include:

• Anterior shoulder stabilization

• Posterior shoulder stabilization

• Superior labrum, anterior to posterior (SLAP) repair

• Diagnostic arthroscopy for internal impingement

• Arthroscopic capsular release for adhesive capsulitis

In addition, some surgeons prefer to perform arthroscopic rotator cuff repair in the lateral decubitus position.

Advantages of the lateral decubitus position over the beach chair position include:

• Improved access to the anterior, inferior, and posterior glenoid

• More ergonomic position for the operating surgeon

• Lower risk for patient cerebral hypoperfusion

• Improved clinical outcomes of shoulder instability surgery ¹

Disadvantages of the lateral decubitus position include:

• Risk of traction-related neurovascular injury

• Requires arm suspension device

• More difficult to rotate the shoulder

• More difficult to convert to open surgery

The lateral decubitus position may be performed with a bean bag placed atop a standard operating table. Alternative equipment options for lateral positioning exist as well, such as peg boards used in combination with foam-wrapped poles to support the patient in a lateral position.

The operating table is rotated 90° for maximal working space within the operating room. A sheet is placed above the bean bag. The patient is first transferred to the OR table and positioned supine with the head of a bed flat. The patient’s head should be at the superior edge of the operating room table, as this will position the operative shoulder closest to the surgeon. The underlying bean bag should be located at the inferior border of the patient’s scapula.

Sequential compressive devices are applied to both lower extremities. General endotracheal anesthesia is performed by the anesthesiology team, and the endotracheal tube is secured to the patient with tape. In addition, this is supplemented with a scalene block for postoperative anesthesia. Using a team approach, the patient is rotated into the lateral decubitus position by first translating the patient toward the operative side with a bedsheet, then turning the patient onto his or her side with the operative arm facing upward.

The patient’s head is supported with a pillow and/or blankets to ensure a neutral position. The patient’s head is not typically fastened with tape for concern of increasing tension on the brachial plexus with traction of the operative upper extremity. However, tape may be applied if a pillow does not provide adequate stability.

The nonoperative arm is flexed forward and rests on a padded arm board. Next, the sides of the bean bag are applied to the patient’s torso to maintain the lateral decubitus position. It is permissible to have the patient’s torso lean posteriorly by 30°, as subsequent arm traction will push the torso into a more neutral position.

With team members holding the bean bag in position, suction is applied to make the bean bag rigid. An axillary roll, consisting of an intravenous saline bag wrapped in a towel, is placed underneath the axilla. Foam padding is placed beneath the “down” leg to minimize pressure on the common peroneal nerve while another foam padding rests between the legs. A bedsheet is placed atop the patient and multiple layers of silk tape are applied to provide additional security to the bean bag. A safety strap is also applied to secure the patient’s torso and lower extremities to the operating room table.

A Smith and Nephew arm jack is positioned on the anterior, proximal side of the OR table. Its specific position is fine-tuned such that it provides 20° of shoulder abduction, which maximizes the glenohumeral joint space. The surgeon may elect to position the arm slightly more anteriorly in cases addressing primarily posterior intra-articular pathology, or more posteriorly in cases addressing primarily anterior intra-articular pathology.

Next, an examination under anesthesia is performed to assess for passive shoulder range of motion in all planes and for stability in both anterior and posterior directions. The operative extremity is then suspended by an intravenous pole for sterile preparation and draping. A nonsterile 10 × 10 drape is placed under the axilla. With the patient positioned, a battery-powered Smith and Nephew Spider pneumatic limb positioner is secured to the posterior and distal portion of the operating room table, with its mobile limb aimed superiorly.

There are multiple alternative commercial arm holders to provide arm traction to perform shoulder arthroscopy in the lateral decubitus position, such as the STAR Arm holder (Arthrex). In addition, a simple “fishing pole” weight and pulley system may be used as well. Rotate the bed to 90° with the head of the patient facing the anesthesiologist to allow the surgeon to stand at the head of the bed with access to both anterior and posterior aspects of the shoulder. Here are images of the patient’s position prior to application of sterile drapes.

After standard preparation of the operative limb with chlorhexidine, standard surgical drapes are applied. The operative arm is placed in a sterile stockinette and wrapped with a self-adherent wrap. We prefer to use an iodine-impregnated drape to wrap the limb circumferentially in all shoulder arthroscopy procedures. A commercial arm-holding device is used to suspend and distract the operative limb. An additional self-adherent wrap is applied to secure the limb to the arm-holding device.

Via the pneumatic arm holder, the arm is positioned in approximately 15° of forward flexion and 30° to 40° of abduction, with the thumb of the operative arm pointing upward. While pushing the operative shoulder forward slightly, axial arm traction is applied and held in place with the arm holder. To reduce risk of neurovascular injury, the minimum amount of traction for adequate visualization should be applied. A sterile towel roll can be placed underneath the arm jack to further increase the glenohumeral joint space and decrease the amount of arm traction required. The operative arm may be disengaged from the arm jack intraoperatively as needed, such as when evaluating range of motion following arthroscopic capsular release. Finally, bony landmarks and planned arthroscopic portal sites are marked with a sterile pen in preparation for the procedure. With appropriate positioning, a circumferential view of the glenohumeral joint can be achieved as shown here.

Thank you.