• Scope

• A 4-mm large joint, 30-degree fiberoptic scope is used for shoulder arthroscopy.

• A 70-degree scope occasionally is used to optimize visualization from the posterior portal around “acute angles” and to limit portal crowding.

• Subscapularis repair, Bankart or anterior labroligamentous periosteal sleeve avulsion (ALPSA) repair, coracoclavicular ligament reconstruction, and distal clavicle excision

• Standard arthroscopy tower

• Monitors (2), light source, shaver motor, radiofrequency ablation source, printer

• Viewing screens are positioned above and below the patient’s head to improve working access in the lateral decubitus position.

• A dual inflow/outflow arthroscopy pump, which tightly controls compartmental fluid pressure, is preferred for fluid management.

• Inflow pressure is set at 35-75 mm Hg depending on bleeding and fluid extravasation factors.

• Epinephrine-infused normal saline (0.33 mg/L) is used for irrigation fluid and has been shown to improve visual clarity, decrease total operative time, and reduce fluid volume utilization.¹

• Intra-articular/subacromial instruments

• Blunt camera trocar and dual port cannula. Inflow tubing is connected to cannula, but no outflow suction is used.

• Graspers. Looped devices with and without teeth are useful for removing loose bodies/foreign material, shuttling suture, and mobilizing tissue.

• Probe.

• Bipolar radiofrequency thermal ablation (RFA) device. We prefer a 90-degree wand.

• Motorized devices. Generally a 3.5- to 4.5-mm bone cutting shaver is adequate for bony and soft tissue debridement (eg, subacromial decompression, distal clavicle excision).

• For sclerotic bone, a 3.0- to 5.0-mm cylindrical burr can be used on the reverse.

• A combination of general anesthesia and interscalene regional blockade is preferred.

• This reduces postoperative pain scores and the need for supplemental analgesics.²

• Paralysis of the hemidiaphragm is a known complication of interscalene blockade and can lead to postoperative respiratory compromise.

• Hypotensive anesthesia is requested to limit blood loss and optimize visual clarity.

• The goal is a <49-mm Hg difference between systolic blood pressure (SBP) and fluid pressure within the surgical compartment, which typically translates to an SBP of ˜100 mm Hg.

• In all shoulders, we screen for selective or global capsular tightness that may require release (Fig. 1-1).

• Translational and provocative stability testing is important to confirm instability direction and severity. This is best performed with the patient supine to allow comparison to the contralateral, unaffected shoulder. The scapula is more easily stabilized in this position.

• Overaggressive load and shift testing, which can cause bleeding and compromise visualization, should be avoided.

• In shoulders with instability, we screen both shoulders for multidirectional laxity.

• General principles

• Communication with the anesthesia team is essential to ensure safe head and neck positioning and a secure airway. The tube is secured to the nonoperative side.

• Unobstructed access to the medial aspect of the operative shoulder is ensured.

• A wide operative field is established; matching the edges of the sterile drapes will help protect against shrinking of the field during draping.

• To protect against fluid extravasation and field contamination, the patient’s arm is placed into the position of traction before the final occlusive layer is applied at the edges.

• Ioban covers the axilla, especially in males, to limit wound contamination.

• All exposed bony prominences are padded.

• Lateral decubitus position (LDP)

• We prefer this position for nearly all shoulder arthroscopic procedures. Lateral traction increases the glenohumeral and subacromial spaces, which is useful for viewing and accessing labral/rotator cuff pathology. Access to the posterior shoulder is unobstructed. In addition, there is no increased risk for patient hypotension/bradycardia, which can cause cerebral hypoperfusion.

• The beach-chair position (BCP) is used when conversion to an open procedure is planned.

• The patient is positioned laterally on a standard operating room table with the operative shoulder facing up. We are careful to move the patient to the top and operative side of the bed to facilitate access during the procedure.

• Foam padding protects the contralateral arm (radial and ulnar nerves), greater trochanter, fibular head (peroneal nerve), lateral malleolus, and heel. Pillows are placed between the knees and ankles.

• A vacuum beanbag is used to secure the pelvis and lower torso in position with a posterior tilt of 20-30 degrees to bring glenoid parallel to floor (Fig. 1-2).

• An axillary roll reduces tension on the brachial plexus and assists ventilation.

• Blue towels and tape and/or heavy straps are helpful to secure the beanbag around the upper torso and prevent malpositioning and posterior shoulder sag during the procedure (Fig. 1-3).

• Lateral arm holder

• We prefer a weighted traction tower anchored at the foot of the nonoperative side of the bed.

• The traction sleeve is positioned high in the axilla to limit slippage (Fig. 1-4).

• Traction (10 lb) is moved between adjustable cables and pulleys to generate varying degrees of abduction and forward flexion.

• Lateral distraction through an axillary strap in slight abduction (20 degrees) creates a lateral force vector that improves access for glenohumeral labral work (Fig. 1-5).