Table of Contents
Diagnostic shoulder arthroscopy or arthroscopic shoulder stabilization procedures can be performed with the patient in the beach chair (BC) or lateral decubitus (LD) position. Patient positioning may be dictated by surgeon preference or the specific intended procedure; however, LD setup has been found to result in lower rates of recurrent instability in cases of anterior arthroscopic stabilization procedures. The lateral and axial traction provided by the LD setup allows for lower suture anchor placement on the anterior-inferior aspect of the glenoid, as the surgeon has increased visualization and working room within the glenohumeral joint. Prior to placing the patient in the LD position, meticulous care must be taken to properly position the beanbag device and set up the lateral traction device. Next, a coordinated team approach should be used to roll the patient into the LD position and to ensure that all bony prominences are adequately padded. The shoulder is then placed in 40° of abduction, 20° of forward flexion, with 10-15 pounds of balanced traction. Finally, the shoulder is prepped and draped in the usual sterile fashion and the surgeon is then able to proceed with the necessary arthroscopic procedure.
Anterior glenohumeral joint instability remains a challenging pathology to address, namely in the young and highly active patient population. In most cases of anterior instability, avulsion of the anteroinferior labrum and the capsular attachments from the glenoid rim (Bankart tear) is present in the 3-6 o’clock position, which commonly results from an impaction force with the shoulder in a hyperabducted and externally rotated position.1,2 Bankart tears can be repaired through a variety of operative techniques, and although open repairs have long been the gold standard for anterior shoulder stabilization, recent reports in the literature demonstrate no significant difference in patient outcomes between open and arthroscopic techniques.3-7 However, it is important to note that despite considerable advancements in surgical techniques and instrumentation, rates of recurrent instability following Bankart repair remain relatively high, ranging from 10% to 30% and worse in patients returning to overhead, contact or collision sports.8-10
The patient is an active 18-year-old female, who denies acute injury, but has had chronic anterior shoulder pain of her right shoulder over the past 2 years and has attempted physical therapy for close to 1 year without any signs of improvement. Relevant to this patient’s history is that she has been a high-caliber volleyball player since a young age, which suggests that her chronic glenohumeral joint pain and recurrent anterior instability are most likely due to the repetitive microtrauma experienced in the hitting shoulder by overhead-hitting athletes. The patient is otherwise healthy and has had no prior injuries to the shoulder, nor did she report any incidents of instability in her contralateral shoulder.
Upon primary physical examination, the patient is a well-appearing female and is neurovascularly intact with no findings of diminished strength of the deltoid and rotator cuff muscles in her right shoulder. She reports 3 dislocation/subluxation events as well as significant apprehension and physical limitations due to these recurrent instability events. She has symptoms consistent with grade II instability (greater than 50% translation with spontaneous reduction) as well as a positive inferior sulcus sign (grade II) and positive relocation test. Physical examinations such as the anterior apprehension test, sulcus sign, relocation test, and load and shift test have demonstrated high sensitivity and specificity in the assessment of anterior shoulder instability, which can significantly aid a surgeon’s preoperative assessment and treatment algorithm.11
A standard radiographic shoulder series (AP/Grashey/Axillary/Scapular Y) is obtained, which upon review demonstrates a well-reduced glenohumeral joint with a well-defined sclerotic line of the anterior glenoid and a normal acromiohumeral distance. There is no discernable anterior glenoid bone loss nor is there an obvious Hill-Sachs lesion present. An MRI without contrast of her right shoulder demonstrates a significant anterior labral tear from the 2 o’clock to 6 o’clock position with no evidence of damage to the biceps tendon or rotator cuff.
Bankart tears develop as a result of anterior glenohumeral dislocation or subluxation and therefore it is imperative to understand the relevant risk factors that may predispose patients to experiencing these instability events. Young male athletes participating in contact or collision sports (football, rugby, wrestling) have been identified to be at the greatest risk of traumatic glenohumeral instability as they are more susceptible to high-velocity impacts and repetitive movements/positions compared to non-contact athletes.12 When reviewing the history of a patient presenting with complaints of anterior instability, it is important to note the underlying pathomechanics of their respective injury, the number of instability events following initial dislocation/subluxation, the time between dislocation and reduction (if applicable), and to identify any pre-existing hyperlaxity. These clinical findings can greatly aid the development of a surgeon’s treatment algorithm and preoperative planning strategies for the management of anterior instability and associated Bankart tears.
When a patient’s focused history, physical exam findings, and imaging findings indicate the need for an arthroscopic Bankart repair to be performed, the surgeon’s preoperative planning and treatment algorithm must address optimal patient positioning based on the extent and location of the Bankart tear. Although positive clinical outcomes have been reported following arthroscopic Bankart repair in both the Beach Chair (BC) and Lateral Decubitus (LD) setups, repairs performed with the patient positioned in a Lateral setup have demonstrated significantly lower rates of recurrent instability following operative treatment.2
When performing arthroscopic shoulder stabilization in the LD position, one of the most significant benefits over the BC position is that the surgeon has increased working space as well as visualization within the glenohumeral joint due to the traction provided by the LD positioner.13 Moreover, the surgeon will have enhanced access to the 6 o’clock position of the glenoid as well as to the inferior and posterior labrum, inferior capsule, subacromial space, and articular side of the rotator cuff.14
Diagnostic shoulder arthroscopy or arthroscopic shoulder stabilization procedures can be performed with the patient in the BC or LD position. Patient positioning may be dictated by surgeon preference or the specific intended procedure and each position carries its inherent advantages and disadvantages. The BC position allows for easy anatomical orientation of the shoulder, provides excellent visualization of the subacromial space and requires minimal equipment and setup time; however, positioning the patient requires multiple team members, and the BC position does not provide optimal access to the inferior and posteroinferior aspect of the glenoid.13,15-17 Although the LD setup requires additional equipment and more intensive training to perform arthroscopic procedures, it avoids many of the complications associated with the BC position, as it allows for greater anterior, inferior and posterior glenoid access and visualization, as well as increased working space within the glenohumeral joint.13,18
Although there is limited available literature that directly compares patient outcomes in the LC versus BC positions for arthroscopic shoulder stabilization, multiple studies have reported outcomes for each separately.2,19-24 A recent systematic review of 64 studies by Frank et al.2 revealed that the BC position has associated rates of recurrent instability of 14.65 ± 8.4% (range, 0% to 38%) following arthroscopic anterior stabilization compared to 8.5% ± 7.1% range, 0% to 30% in the LD position (p = 0.002). However, there were no significant differences reported between the two positions in regard to postoperative loss of range of motion. One explanation for the discrepancies in rates of recurrence between the 2 patient positions is that operative success depends on the surgeon’s ability to place an adequate number of anchors on the anterior inferior glenoid rim in order to provide capsular tensioning. As the most common zone of injury in cases of anterior instability is in the anterior-inferior portion of the glenoid and labrum, the surgeon and overall outcomes of the procedure may benefit from the increased 3 to 6 o’clock access provided by the LD position.25 Further studies that directly compare outcomes in either the LD or the BC position are required in order to decisively determine optimal patient positioning for arthroscopic anterior stabilization.
- Arthrex Shoulder Suspension System
- 1015 U-Drapes, Ioban Drapes, and rectangular drapes
- Circular head pad, axillary roll and bean bags
- Standard shoulder arthroscopy set
Matthew T. Provencher has the following disclosures to report: Is a paid consultant for Arthrex and the Joint Restoration Foundation (Allosource); receives intellectual property royalties from Arthrex; receives publishing royalties from SLACK Inc; is an editorial or governing board member for Arthroscopy, Knee, Orthopedics, and SLACK Inc; and is a board or committee member for AANA, AAOS, AOSSM, ASES, ISAKOS, the San Diego Shoulder Institute, and the Society of Military Orthopaedic Surgeons.
All other authors (L.A.P. and Z.S.A.) have no disclosures to report.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Loh B, Lim JBT, Tan AHC. Is clinical evaluation alone sufficient for the diagnosis of a Bankart lesion without the use of magnetic resonance imaging? Ann Transl Med. 2016;4(21):419. doi:10.21037/atm.2016.11.22.
- Frank RM, Saccomanno MF, McDonald LS, Moric M, Romeo AA, Provencher MT. Outcomes of arthroscopic anterior shoulder instability in the beach chair versus lateral decubitus position: a systematic review and meta-regression analysis. Arthroscopy. 2014;30(10):1349-1365. doi:10.1016/j.arthro.2014.05.008.
- Imhoff AB, Ansah P, Tischer T, et al. Arthroscopic repair of anterior-inferior glenohumeral instability using a portal at the 5:30-o'clock position: analysis of the effects of age, fixation method, and concomitant shoulder injury on surgical outcomes. Am J Sports Med. 2010;38(9):1795-1803. doi:10.1177/0363546510370199.
- Mologne TS, Provencher MT, Menzel KA, Vachon TA, Dewing CB. Arthroscopic stabilization in patients with an inverted pear glenoid: results in patients with bone loss of the anterior glenoid. Am J Sports Med. 2007;35(8):1276-1283. doi:10.1177/0363546507300262.
- Nho SJ, Frank RM, Van Thiel GS, et al. A biomechanical analysis of anterior Bankart repair using suture anchors. Am J Sports Med. 2010;38(7):1405-1412. doi:10.1177/0363546509359069.
- Brophy RH, Marx RG. The treatment of traumatic anterior instability of the shoulder: nonoperative and surgical treatment. Arthroscopy. 2009;25(3):298-304. doi:10.1016/j.arthro.2008.12.007.
- Harris JD, Gupta AK, Mall NA, et al. Long-term outcomes after Bankart shoulder stabilization. Arthroscopy. 2013;29(5):920-933. doi:10.1016/j.arthro.2012.11.010.
- Lenters TR, Franta AK, Wolf FM, Leopold SS, Matsen FA III. Arthroscopic compared with open repairs for recurrent anterior shoulder instability. A systematic review and meta-analysis of the literature. J Bone Joint Surg Am. 2007;89(2):244-254. doi:10.2106/JBJS.E.01139.
- Uhorchak JM, Arciero RA, Huggard D, Taylor DC. Recurrent shoulder instability after open reconstruction in athletes involved in collision and contact sports. Am J Sports Med. 2000;28(6):794-799. doi:10.1177/03635465000280060501.
- Dickens JF, Owens BD, Cameron KL, et al. Return to play and recurrent instability after in-season anterior shoulder instability: a prospective multicenter study. Am J Sports Med. 2014;42(12):2842-2850. doi:10.1177/0363546514553181.
- Lizzio VA, Meta F, Fidai M, Makhni EC. Clinical evaluation and physical exam findings in patients with anterior shoulder instability. Curr Rev Musculoskelet Med. 2017;10(4):434-441. doi:10.1007/s12178-017-9434-3.
- Owens BD, Agel J, Mountcastle SB, Cameron KL, Nelson BJ. Incidence of glenohumeral instability in collegiate athletics. Am J Sports Med. 2009;37(9):1750-1754. doi:10.1177/0363546509334591.
- Peruto CM, Ciccotti MG, Cohen SB. Shoulder arthroscopy positioning: lateral decubitus versus beach chair. Arthroscopy. 2009;25(8):891-896. doi:10.1016/j.arthro.2008.10.003.
- Li X, Eichinger JK, Hartshorn T, Zhou H, Matzkin EG, Warner JP. A comparison of the lateral decubitus and beach-chair positions for shoulder surgery: advantages and complications. J Am Acad Orthop Surg. 2015;23(1):18-28. doi:10.5435/JAAOS-23-01-18.
- Higgins JD, Frank RM, Hamamoto JT, Provencher MT, Romeo AA, Verma NN. Shoulder arthroscopy in the beach chair position. Arthrosc Tech. 2017;6(4):e1153-e1158. doi:10.1016/j.eats.2017.04.002.
- Rains DD, Rooke GA, Wahl CJ. Pathomechanisms and complications related to patient positioning and anesthesia during shoulder arthroscopy. Arthroscopy. 2011;27(4):532-541. doi:10.1016/j.arthro.2010.09.008.
- Skyhar MJ, Altchek DW, Warren RF, Wickiewicz TL, O'Brien SJ. Shoulder arthroscopy with the patient in the beach-chair position. Arthroscopy. 1988;4(4):256-259. doi:10.1016/S0749-8063(88)80040-9.
- Hamamoto JT, Frank RM, Higgins JD, Provencher MT, Romeo AA, Verma NN. Shoulder arthroscopy in the lateral decubitus position. Arthrosc Tech. 2017;6(4):e1169-e1175. doi:10.1016/j.eats.2017.04.004.
- Ahmed I, Ashton F, Robinson CM. Arthroscopic Bankart repair and capsular shift for recurrent anterior shoulder instability: functional outcomes and identification of risk factors for recurrence. J Bone Joint Surg Am. 2012;94(14):1308-1315. doi:10.2106/JBJS.J.01983.
- Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006;88(8):1755-1763. doi:10.2106/JBJS.E.00817.
- Privitera DM, Bisson LJ, Marzo JM. Minimum 10-year follow-up of arthroscopic intra-articular Bankart repair using bioabsorbable tacks. Am J Sports Med. 2012;40(1):100-107. doi:10.1177/0363546511425891.
- Bottoni CR, Smith EL, Berkowitz MJ, Towle RB, Moore JH. Arthroscopic versus open shoulder stabilization for recurrent anterior instability: a prospective randomized clinical trial. Am J Sports Med. 2006;34(11):1730-1737. doi:10.1177/0363546506288239.
- Thal R, Nofziger M, Bridges M, Kim JJ. Arthroscopic Bankart repair using Knotless or BioKnotless suture anchors: 2- to 7-year results. Arthroscopy. 2007;23(4):367-375. doi:10.1016/j.arthro.2006.11.024.
- Mishra A, Sharma P, Chaudhary D. Analysis of the functional results of arthroscopic Bankart repair in posttraumatic recurrent anterior dislocations of shoulder. Indian J Orthop. 2012;46(6):668-674. doi:10.4103/0019-5413.104205.
- Roth CA, Bartolozzi AR, Ciccotti MG, et al. Failure properties of suture anchors in the glenoid and the effects of cortical thickness. Arthroscopy. 1998;14(2):186-191. doi:10.1016/S0749-8063(98)70039-8.
Table of Contents
- Once asleep, patient is turned onto their side and axillary roll is placed 3 finger widths below axillary space
- Patient’s head is placed on circular pad and all sensitive areas are padded, namely between the thighs and shins so the fibular head does not compress surrounding neurovascular structures
- A belt and surgical tape are used to secure the patient onto the bed in the lateral position to prevent movement during the procedure
- 1015 U-drapes (3M) are used for the original draping around the operative arm
- The lateral positioner (Arthrex) is attached to the side of the bed the patient is facing such that the operative arm comes across the patient body
- After positioner setup, the patient is then draped with 1 rectangular drape over their body and 2 additional U-drapes, 1 with a pouch to collect arthroscopic fluids, that are finally covered with Ioban drapes around the perimeter to prevent water leaking underneath
- The patient’s hand is made into a fist and secured in the hand holder by Velcro straps. The hand holder is then clipped to the sterile portion of the lateral positioner and 12.5 pounds of counterweight is applied to start, which can be increased to as much as 15 pounds
- The axillary pad is then strapped to the end of the positioner and approximately 20 pounds of traction is applied to increase glenohumeral joint space
- Standard arthroscopy setup follows, including a shoulder arthroscopy set with tubes, a shaver, Bovie tip with Colorado tip, water, cannula and outflow devices
The key is to have this all the way up against the axilla. Thumb neutrally positioned here. You can leave the towel in and then you overlap the foam, like that. Foam is overlapped and then the velcro goes over. The key is having this all over the axilla so we can get the lateral strap in place. Okay, so this lateral strap is very important - it just helps you with lateral translation of the glenohumeral joint. The next thing is this thing is also designed - so look here - to rotate - relax - see how I can rotate this, a little bit? We're going to keep it in a neutral - neutral position, so now I can rotate the arm. Put this up here. We already know that he has instability. You get this nice balanced suspension and so you have 45 degrees of abduction, 15 of forward flexion, and then a balanced lateral translation here - that just opens up the joint gently. Be really careful with this to make sure it's on the foam, and I take it off as soon as we're done, but it's so worked out very well without any issues - and it’s just a light amount of traction - 10 lbs.