Patient Positioning and Anesthesia for Rotator Cuff Surgery


Chapter 11

Patient Positioning and Anesthesia for Rotator Cuff Surgery



Benno Ejnisman, and Paulo Santoro Belangero

Introduction


Shoulder arthroscopy can be performed with the patient in either the lateral decubitus position (LDP) or the beach chair position (BCP). There are advantages and disadvantages of both positions with respect to the ease, efficiency, and economics of setup; conversion to an open approach; orientation and visualization; the best type of anesthesia; and the complications and risks. Regardless of the position used, improper setup can result in greater complexity and technical difficulty. However, historically, a surgeon’s preference for patient positioning has been based largely on training.

Shoulder arthroscopy can be done with the patient under general or regional anesthesia. However, in a recent review of 9410 elective shoulder arthroscopy cases, 90.7% involved general anesthesia. Positioning during shoulder arthroscopy may affect the type of anesthesia used. In the BCP, it is possible to use general or regional anesthesia (interscalene block). However, regional anesthesia is poorly tolerated by patients in the LDP, so the preference for this position is general anesthesia. More details are presented in the following.

Procedure


Description of the BCP and LDP


In 1988, Skyhar et al. first reported the use of the BCP (Fig. 11.1) for arthroscopic shoulder procedures, citing a number of potential advantages. To achieve the LDP (Fig. 11.2) for shoulder arthroscopy, the patient is placed laterally on a standard operating table with the operative shoulder exposed vertically. A beanbag and/or other stabilizing device, such as straps or braces, is used for support.

Treatment Options: Nonoperative and Operative


Options for Patient Position





  1. • Few studies have directly compared BCP and LDP. Surgeon’s preference, surgeon’s experience level, and the specific intended procedure often dictate which position is used. With appropriate setup and positioning, both techniques are reliable with low complication rates. The BCP offers the advantage of easy conversion to open techniques, whereas the LDP may allow for lower suture anchor position on the glenoid. In 2014 an interesting review and meta-regression analysis of the outcomes of arthroscopic anterior shoulder stability showed that patient position was a potential factor less discussed in the literature and that its contribution to the recurrence of instability had not been yet reported. The results showed that the recurrence of instability was significantly higher with the BCP when considering either all procedures or only those using suture anchors. There was no difference regarding postoperative external rotation, rates of return to activity or sports activity, postoperative Rowe score, and postoperative Constant-Murley score. Despite these findings, many other factors, regardless of patient position, are critical to the success or failure of the procedure, including appropriate indications, patient selection criteria, adequate debridement and mobilization of the capsulolabral tissue, sufficient capsulolabral tensioning, careful suture management and knot placement, and adequate quantity of suture anchors and treatment of concomitant injuries, as well as their effects, could not be considered in this meta-analysis. Likewise, the meta-regression analysis has important limitations regarding the quality of the studies, most of them of level III or IV, and no included article directly compared BCP and LDP.

  2. image
    FIG. 11.1 Patient in beach chair position.



  4. image
    FIG. 11.2 Patient in lateral decubitus position.

  5. • Another study in which researchers studied cadavers to compare BCP and LDP for establishing an anteroinferior shoulder portal showed that the musculocutaneous nerve and the cephalic vein are the neurovascular structures more prone to being injured with the LDP than in the BCP when creating the portal.
  6. • Regardless of the type of procedure, the most controversial aspects of using the BCP vs. the LDP are related to the ease of setup, the possibility of conversion to an open approach, and the orientation and visualization of the operative field. Currently the best type of anesthesia and the complications and risks of each procedure in shoulder arthroscopy are also discussed in depth.

Anesthetic Options





  1. • Shoulder arthroscopy can be done with the patient under general or regional anesthesia. However, in a recent review of 9410 cases of elective shoulder arthroscopy, 90.7% involved general anesthesia. Positioning during shoulder arthroscopy may affect the type of anesthesia used. In the BCP, it is possible to use general or regional anesthesia (interscalene block). However, regional anesthesia is poorly tolerated in patients in the LDP, so the preference with this position is general anesthesia. With interscalene block, the patient is awake and can assist in controlling his or her head.
  2. • Few data exist on the combined use of general anesthesia and intraoperative or postoperative interscalene block. In principle, combined anesthetics will lead to additive complication risk. In a recent, prospective, randomized, blinded study, the authors found no difference between groups regarding decreased blood pressure or heart rate (Jansen H et al, 2014).
  3. • The benefits of ultrasound guidance during the placement of interscalene blocks have also been studied. A successful block (defined as delivery of anesthetic in proximity to the nerve) was achieved in 95% of patients (Abrahams MS et al, 2009). A meta-analysis by Abrahams et al. found ultrasound guidance to be superior to electrical neurostimulation techniques with respect to block success, faster block performance, shorter time to block onset, and longer duration of efficacy. Ultrasound-guided blocks had lower rates of iatrogenic vascular puncture and hematoma formation.
  4. • Gonano et al. compared the economic aspects of interscalene brachial plexus blockade (ISB) with general anesthesia for arthroscopic shoulder surgery in BCP. Although the fixed costs were lower in the ISB group, the difference of 8 euros per case is of limited economic relevance compared with overall surgery room costs. However, in the ISB group, the anesthesia control time was almost halved; there was less demand for pain therapy and for therapy for nausea and vomiting; and only 10% of patients vs. 60% in the general anesthesia group needed vasopressor therapy during the surgical procedure. Thus, less fluids and vasopressor drugs are required when regional anesthesia is used for shoulder surgery in the sitting position.

Surgical Indications


Factors Considered Important in Deciding Between BCP and LDP





  1. • Ease of setup: supporters of the LDP and BCP each claim that the position they defend is the easiest and fastest to employ. Important aspects are related to the assistance required to set up and perform the arthroscopy and the cost of setup.
  2. • Assistance requirement: both positions require assistance, and both may require adjustments to be made during surgery that can add to surgical time. For the LDP, assistance is required to turn and secure the patients after they have been anesthetized and for the addition of traction and any adjustments that are made to the traction. In the LDP, a scrubbed assistant may be required to hold the humerus or arm in internal or external rotation during the surgery. Achieving the proper BCP takes time to secure the head, neck, and torso. For the BCP, an assistant may be required to apply traction during surgery if a mechanical arm holder is not available or if the joint requires distraction for instability procedures. Despite the use of a mechanical arm holder, an assistant may still be required to pull traction on the arm in the BCP.
  3. • Cost of setup: this aspect was well presented in a concise review by Peruto et al.:


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Hemiarthroplasty for Rotator Cuff Deficiency: Indications and Technique Arthroscopic Rotator Cuff Repair: Instruments, Portal Placement, and Devices Long Head of the Biceps Tenodesis: Proximal Soft Tissue Fixation Without Anchors SLAP II Tears: Evaluation and Surgical Techniques for Fixation Impingement Syndrome: Diagnosis and Management Shoulder Stiffness (Adhesive Capsulitis) With A Rotator Cuff Tear: How to Manage

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Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on Patient Positioning and Anesthesia for Rotator Cuff Surgery

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