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TECHNIQUE

Economical and Efficacious Beach Chair Traction


Positioning for Shoulder Arthroscopy
Amr ElMaraghy, MD, FRCSC,*w Amanda Pennings, HBSc, MScPT,w and Moira Devereaux, MScPTz

intuitive anatomic orientation.7 In cases that require con-


Abstract: This study describes a modified beach chair technique that version to an open procedure, the ergonomics of the lateral
allows the application of continuous traction to the operative arm decubitus method sometimes necessitates patient repositioning
during arthroscopic shoulder surgery. The difference in costs for the and redraping.6 The lateral decubitus position has been asso-
equipment and resources, setup time, and overall procedure time for 33 ciated with neurovascular complications, including peripheral
cases performed using standard beach chair (SBC) positioning and 34 neurapraxia, brachial plexopathy, and direct nerve injury.6,8–10
cases performed using a beach chair traction (BCT) technique was The conventional beach chair position presents the anat-
documented and compared. The incremental 1-time equipment setup omy of the shoulder in the more familiar upright anatomic
cost for the BCT technique was $748 CDN, with an ongoing incre- position, minimizing spatial disorientation.6,8 It can be easily
mental cost of $65 CDN per procedure. Setup time for the SBC group converted to an open procedure and tends to provide a more
averaged 26 ± 8 minutes compared with 28 ± 8 minutes for the BCT accessible airway for anesthetists.2,4,8,10 Reported complica-
group. The surgical procedure time was not significantly different and tions with the use of the beach chair position include hypo-
averaged 70 ± 21 minutes for the SBC group and 65 ± 17 minutes for glossal and cervical plexus nerve injury, hypotensive and
the BCT group. The BCT technique produced a noticeable increase bradycardic events, and cerebral oxygen desaturation and
in both the glenohumeral and subacromial spaces by visual impres- cerebral hypoperfusion.7,10–12 Beyond the need to purchase the
sion. The increased space resulted in improved scope of visualiza- beach chair itself, the technique requires minimal additional
tion and enhanced instrumentation maneuverability. This BCT equipment, and the operative arm is usually draped free.
technique combines the operative benefits of traction and lateral dis- However, there are only a few reports of use of traction in the
traction during shoulder arthroscopy in the conventional and anatom- beach chair position, and continuous traction is usually not a
ically familiar beach chair position, with only minimal impact on cost standard part of this position. Traction during the procedure is
and setup time. usually applied manually by an assistant or with devices that
Key Words: beach chair, shoulder arthroscopy, shoulder positioning maintains the arm in a static position during the arthroscopic
(Tech Should Surg 2012;13: 170–176)
procedure.
Recent reports in the literature describe techniques
intended to obtain the main benefit of the lateral decubitus
position, namely improved safety and visualization due to

A rthroscopy of the shoulder has become a routine surgical


procedure for the diagnosis and treatment of a multitude of
disorders. It is most commonly performed in the lateral
static lateral distraction and longitudinal traction, while
maintaining the benefits and anatomic familiarity of the beach
chair position.2,4,8,13,14 However, the amount of detail in the
decubitus or beach chair position.1,2 Both positions have their description of each beach chair traction (BCT) positioning
relative advantages and disadvantages and the choice between technique is highly variable. To date, no report has described
the 2 is largely a matter of surgeon training, experience, and the economical feasibility and accessibility of the materials
preference.1–6 Operating in the glenohumeral joint and sub- used for BCT, the impact on overall setup and procedure times,
acromial space can be a significant challenge with limited or comparison with a control (ie, conventional beach chair
clearance available for arthroscopic instrumentation, especially positioning).
with certain pathologies and in smaller patients. It is therefore The purpose of this paper is to describe our experience
beneficial to apply traction on the arm, often manually, to with our own BCT positioning technique, using materials that
displace the humeral head for arthroscopic accessibility. are readily accessible in a standard operating room (OR). We
The lateral decubitus position offers stable, sustained hypothesized that the BCT technique will be economical and
patient positioning while enabling static traction of the arm in efficacious and result in improved intraoperative efficiencies as
the desired position of abduction and forward flexion.4 Trac- compared with the standard beach chair (SBC) position.
tion, often accompanied by lateral distraction, makes the gle-
nohumeral interval more pronounced, allowing for controlled,
atraumatic entrance into the joint space, easy access to the MATERIALS AND METHODS
inferior and posterior labrum and capsule, and improved vis- Upon receiving ethics approval from our Institutional
ualization.5,6 However, lateral decubitus traction devices can Review Board, we conducted a retrospective chart review of
be bulky and cumbersome to set up.2 Moreover, the lateral consecutive shoulder arthroscopic procedures performed in the
position presents the shoulder anatomy in a rotated and less SBC position between June 2008 and October 2008 and pro-
cedures performed in the BCT position between October 2008
From the Departments of *Surgery, Division of Orthopaedic Surgery,
and February 2009. Patients undergoing arthroscopic rotator
University of Toronto; zPhysical Therapy, Division of Rehabilitation cuff decompression and/or rotator cuff repair procedures met
Sciences, University of Toronto; and wDepartment of Orthopaedic Surgery, the inclusion criteria for this study. Study patients who had
St. Joseph’s Health Centre, Toronto, ON, Canada. other simple procedures concomitant to their rotator cuff sur-
The authors declare no conflict of interest.
Reprints: Amanda Pennings, HBSc, MScPT, 27 Roncesvalles Ave., Suite 504,
gery (ie, distal clavicle excision, labral debridement, capsular
Toronto, ON, Canada M6R 3B2 (e-mail: amanda.l.pennings@gmail.com). release, manipulation under anesthesia, and biceps tenotomy)
Copyright r 2012 by Lippincott Williams & Wilkins were also included. We excluded open shoulder procedures,

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Techniques in Shoulder & Elbow Surgery  Volume 13, Number 4, December 2012 Beach Chair Traction for Shoulder Arthroscopy

for which the SBC positioning without continuous traction is


used exclusively, and patients undergoing arthroscopic labral TABLE 1. Incremental Materials for Beach Chair Traction
Positioning Technique
and/or instability repairs due to a low frequency of exposure.
Data collection was conducted for 2 groups. Group I consisted Reusable Cost
of procedures performed in the SBC position (n = 33). Group II Item Standard Per Item Consumable Cost
consisted of procedures performed using the BCT positioning Description OR Issue ($ CDN) Per Item ($ CDN)
technique (n = 34). To recognize the potential impact of U-shaped Yes $ 400.00 —
adopting a new technique in the OR of a university-affiliated bolster to act
teaching hospital, we felt that it was important to ensure any as pulley
learning curve associated with implementation of the new BCT Clamp to attach Yes $ 114.00 —
position was acknowledged in our methodology. Therefore, we bolster to bed
compared the first 34 cases performed using the new technique Phase 4 gel No — $ 49.50
with the last 33 cases we performed using the conventional splint*
Six-inch elastic Yes — $ 0.49
beach chair position that had been standard practice in our bandage
institution for nearly a decade. Sterile “axillary Yes — $ 15.00
The same surgeon performed all arthroscopic procedures roll”
and participated in all setup activities in the OR. The assisting Traction No $ 234.00 —
staff rotated and varied in number and included residents, weightsw
fellows, surgical assistants, and nurses. Data were collected Total 1-time — $ 748.00 —
from the hospital’s standardized operating report forms. setup costz
Patient demographics for each group included sex, age, weight, Total ongoing — — $ 64.99
height, and affected side. Time data included patient entry into costy
the OR, surgical start time (ie, scalpel to skin), surgical end *Although this item has limited reuse capabilities, it will be classified as
time (ie, sutures completed), and patient exit from the OR. The consumable for the purposes of cost analysis in this paper.
order in which the surgical case occurred during the day, the wIncludes weight hanger rod and 4 slotted disk weights (2 5 and
2  2.5 lbs).
number of surgical assistants present, and the application of zCost of all items (if not already present and accessible in the OR).
regional nerve block was also noted. yPer-case cost for consumable items.
Statistical analyses were performed using SPSS v17.0. OR indicates operating room.
Data were characterized using descriptive statistics (mean, SD,
range, and frequency). w2 tests were applied to compare group
frequencies. Independent t tests were performed to identify
differences between group means. P values < 0.05 were con- Patients in group II (BCT) were positioned in the same
sidered significant. SBC as above, with incremental reusable and consumable
materials applied to set up the traction position (Table 1). At
this level of traction, no additional bolsters or counter traction
Set Up was necessary over and above the features of the SBC. A
Patients in group I (SBC) were positioned on a com- nonsterile impervious stockingette was applied above the
mercially available, TENET’s T-MAX Beach Chair (TENET elbow on the operative side. A forearm phase 4 gel traction
Medical Engineering Inc., Calgary, Canada) with the upper splint (Innovative Medical Products Inc., Plainville, CT) was
end elevated to approximately 60 degrees and the patient’s legs then applied over the stockingette (Fig. 1A) and secured firmly
placed on a triangular pillow. In this position, the patient’s to the operative forearm by wrapping a 6-inch nonsterile
head was secured, lateral bolsters applied, and the non- elastic bandage from just below the elbow to the hand. The
operative arm placed on a padded support. The patient’s stockingette was then folded back distally over the forearm,
operative shoulder was positioned off the edge of the table (for thereby exposing the entire arm to just past the elbow, and
anterior and posterior access) with the operative arm rested on covering the forearm splint with impervious material. Two
a padded, sterile-draped Mayo stand. No routine manual or tails of coated braided metal cable were attached to the traction
sustained traction maneuvers were applied in this group. splint with metal carabiners and extend from the distal aspect

FIGURE 1. A, The impervious stockingette is applied and rolled up past the elbow of the operative forearm. The phase 4 gel forearm
traction splint is applied to the hand and forearm. B, The 6-inch elastic bandage is wrapped firmly from just below the elbow to the
hand. Pulling on the cables ensures that traction is secure while the arm is maintained in abduction and forward elevation.

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ElMaraghy et al Techniques in Shoulder & Elbow Surgery  Volume 13, Number 4, December 2012

FIGURE 2. A, The sterile flannel is wrapped firmly from above the elbow until the end of the forearm traction splint. B, The cables are
passed over the U-shaped bolster, and once the appropriate weight has been attached, a stable beach chair traction position is achieved.

of the splint. Pulling on these cables was performed to test that over the nonsterile bolster by the assistant, and a weighted
the traction to the arm was secure (Fig. 1B). The arm was then hook was applied (Fig. 2B). With the arm in this now stable
placed in the desired position for surgery. A U-shaped bolster, position, the hand and pulley system were covered with a
acting as a pulley, was then attached more distally to the simple sterile flat sheet. The remainder of the draping was
operative bedside by a standard round clamp and positioned completed, and the arthroscopic equipment was assembled in
such that, when the cables from the forearm traction splint the standard manner.
were drawn over the support, the arm was maintained in the Effective lateral distraction of the glenohumeral joint is
desired position of approximately 15- to 20-degree abduction also an integral component of the BCT positioning technique.
and forward elevation. To achieve this lateral distraction, a lateral vector of the
Before definitively applying the weights to gain the longitudinal traction force being applied through the weights
desired amount of traction force, the arm was held by an must be created. This was accomplished by tightly rolling 2
assistant in wide abduction to allow access to the underarm and sterile gowns and covering these with 1 or more sterile green
upper chest for thorough skin preparation. The standard sur- towels creating a firm axillary roll, which was positioned
gical U drapes were then applied. As the arm was brought proximally between the medial aspect of the upper arm and the
slowly to the traction position, the surgeon wrapped from lateral aspect of the upper chest (Fig. 3). The axillary roll must
above the elbow proximally to the hand distally with a sterile be positioned before introduction of the camera trochar to
6-inch flannel bandage (Fig. 2A). The cables were directed minimize damage to the articular surfaces. It is also helpful to
mark the bony surface anatomy only after final positioning of
the arm, including the presence of the axillary roll, as the
traction and lateral distraction can slightly alter the skin
position overlying relevant bony landmarks.
The amount of traction force necessary can vary with sex
(usually 7 to 10 pounds for females, 9 to 12 pounds for males),
body size, and procedure performed. The weights could be
increased, decreased, or removed during the procedure by
having a circulating assistant work under the sterile flat sheet.

TABLE 2. Comparison of Procedures Performed


Group I Group II
Arthroscopic Standard Beach Beach Chair
Procedure Chair (n = 33) Traction (n = 34) P
Decompression 10 11 0.83
Decompression + AC 4 6 0.53
joint excisions
Decompression + AC 3 4 0.71
joint excision + repair
Decompression + repair 9 7 0.62
Decompression + other* 7 6 0.78
*Includes labral debridement, capsular release, manipulations under anes-
FIGURE 3. The final beach chair traction position with the thetic, and biceps tenotomy.
U-shaped bolster and weights draped with a sterile flat sheet and an AC indicates acromioclavicular.
added axillary roll (arrow) to achieve effective lateral distraction.

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Techniques in Shoulder & Elbow Surgery  Volume 13, Number 4, December 2012 Beach Chair Traction for Shoulder Arthroscopy

TABLE 3. Patient Demographics


RESULTS
Compared with the SBC method, the BCT technique is
Group I Group II associated with a 1-time incremental setup cost of $748 CDN,
Standard Beach Beach Chair with an ongoing incremental cost of $65 CDN for consumables
Description Chair (n = 33) Traction (n = 34) P per each surgical case completed (Table 1).
Male 22 20 0.76 Between groups, there were no statistically significant dif-
Female 11 14 0.55 ferences in the number or type of procedures performed or in
Age (y) 47 49 0.36 patient demographics (Tables 2, 3). No statistically significant
Height (cm) 166 171 0.36 differences were observed between groups in the order the pro-
Weight (kg) 84 85 0.79 cedures occurred (ie, case number of the day), number of assis-
Affected 20 21 0.88 tants present, or application of regional nerve block [performed
side—right
Affected 13 13 1.00
prior and in addition to application of a general anesthetic for
side—left 88% (29 of 33) of patients in group I and 91% (31 of 34) of
patients in group II]. Maximum of 1 surgical assistant was
required to complete each procedure. No postoperative neuro-
vascular complications were noted in either group.
The position of the body and/or pulley could also be changed There was no statistical difference between the groups in
to facilitate different locations during the procedure. For the amount of time required for set up or time to exit the OR
example, effective forward flexion improves visualization of (Table 4). Although there was no statistical difference in the
anterior subdeltoid structures (ie, subscapularis, coracoid, and duration of the surgical procedure, mean surgical time was less
long head of biceps). Similarly, the size and exact position of using the BCT technique (65 ± 17 min) than when using SBC
the axillary roll can be varied to maximize the lateral vector positioning (70 ± 21 min), which is attributed at least in part to
achieved by the longitudinal traction weight and improve increased glenohumeral and subacromial spaces leading to
visualization after establishing the posterior viewing portal for improved visualization and instrumentation access (Table 4).
intra-articular structures and in cases of adhesive capsulitis.
After all intra-articular procedures were completed and just
before leaving the glenohumeral joint, the axillary roll was DISCUSSION
removed to allow optimal visualization of the articular surface To gain the benefits of traction, a number of variations to
of the rotator cuff and/or the “footprint” of the tuberosity in the SBC position have been reported.2,4,8,13,14 Hoenecke et al4
cases of articular-sided partial thickness rotator cuff tears. were the first to report on a “modified beach chair position”
Without the axillary roll, longitudinal traction is maximized, that used a customized foam pillow to tilt a supine patient
making it easier to complete all necessary subacromial surgery. toward their nonoperative side in a 45-degree lateral position,
Manipulations under anesthetic, as with capsular release pro- although this position is ultimately closer to the lateral decu-
cedures, were performed by maintaining the coverage of the bitus position. More recently, Kim et al8 applied traction in a
flat sheet during the manipulation or covering the hand and beach chair position by using a standard lateral decubitus
forearm with a sterile bag then restoring the arm to the traction position 3-point shoulder holder attached to the ipsilateral side
position under a new sterile sheet if desired. of the operating table; however, the mechanical arm holder

TABLE 4. Impact on Surgical Times


No. OR Entry to Surgical Total Surgical Surgical End to OR Total OR Time
Arthroscopic Procedure Procedures Start (min) Time (min) Exit (min) (min)
Group I—Standard Beach Chair
Decompression 10 27 ± 11 (14-50) 57 ± 12 (30-75) 10 ± 5 (5-21) 94 ± 20 (65-131)
Decompression + AC joint 4 20 ± 0.5 (20-21) 57 ± 10 (44-65) 10 ± 4 (5-15) 87 ± 6 (80-95)
excision
Decompression + AC joint 3 30 ± 5 (25-34) 78 ± 13 (65-90) 10 ± 5 (5-15) 118 ± 15 (100-128)
excision + repair
Decompression + repair 9 25 ± 8 (15-35) 83 ± 17 (60-115) 9 ± 4 (3-15) 117 ± 17 (95-143)
Decompression + other* 7 26 ± 9 (15-45) 73 ± 30 (45-120) 12 ± 7 (5-25) 112 ± 25 (80-145)
All procedures 33 26 ± 8 (14-50) 70 ± 21 (30-120) 10 ± 5 (3-25) 106 ± 21 (65-145)
Group II—Beach Chair Traction
Decompression 11 24 ± 4 (20-30) 50 ± 10 (35-70) 8 ± 5 (5-20) 82 ± 9 (65-120)
Decompression + AC joint 6 27 ± 9 (15-40) 68 ± 19 (45-100) 8 ± 6 (4-20) 103 ± 14 (82-120)
excisions
Decompression + AC joint 4 29 ± 3 (25-30) 84 ± 12 (75-100) 16 ± 9 (10-28) 128 ± 20 (115-158)
excision + repair
Decompression + repair 7 29 ± 12 (14-50) 74 ± 13 (50-90) 10 ± 4 (5-15) 113 ± 24 (80-150)
Decompression + other* 6 33 ± 8 (20-40) 68 ± 15 (50-90) 10 ± 3 (5-15) 111 ± 13 (99-135)
All procedures 34 28 ± 8 (14-50) 65 ± 17 (35-100) 10 ± 5 (4-28) 103 ± 23 (65-158)
P 0.29 0.35 0.79 0.63
Time (min) data indicate mean ± SD with minimum and maximum values in parentheses.
P < 0.05 indicates statistical significance.
*“Other” includes labral debridement, capsular release, manipulations under anesthetic, and biceps tenotomy.
AC indicates acromioclavicular; OR, operating room.

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ElMaraghy et al Techniques in Shoulder & Elbow Surgery  Volume 13, Number 4, December 2012

FIGURE 4. A, Visualization of the glenohumeral joint of a right shoulder from the posterior portal in the standard beach chair position.
B, The same shoulder, with improved visualization of the glenohumeral joint from the posterior portal in the beach chair traction
position with an axillary roll. C, Visualization of the glenohumeral joint from the anterior portal in the standard beach chair position. D,
The same shoulder, with improved visualization of the glenohumeral joint from the anterior portal in the beach chair traction position
with an axillary roll. (G indicates glenoid; H, humeral head; L, labrum).

device is expensive and requires additional custom mod- reuse, resulting in potentially an even lower ongoing cost. We
ifications. Correa et al2 described the use of a custom, feel that this is a much more cost-effective alternative to the
“inverted L-shaped” device clamped to the ipsilateral side of standard purchase of a lateral decubitus traction bar ($2000 to
the bed to universally position a cylindrical rod in the beach $4500 USD) and/or a high-quality beach chair mechanical arm
chair position, requiring custom traction clamp equipment and holder ($8000 to $12,000 USD), both of which still necessitate
application of traction directly to the wrist and hand. Kilinc the purchase of ongoing usually single-use forearm sleeves.6
et al15 used a Foley catheter as a balloon to achieve internal The BCT technique allowed for the benefits of traction in a
subdeltoid distraction, although this technique may be cum- beach chair position without negatively affecting surgical timing,
bersome and does not address the need for an increased gle- resources, or the work of the surgical assistant during arthro-
nohumeral interval. All of these authors have also failed to scopic shoulder procedures. The new BCT positioning required
compare their customized techniques with the conventional on average 2 minutes longer in setup time than cases using the
beach chair position. SBC position. The actual surgical time for the procedures
Assuming that a surgeon is already using the SBC posi- averaged 5 minutes less for BCT cases; although this time sav-
tion, most of the incremental materials we use to apply the ings was not statistically significant, surgeons not in teaching
traction technique are readily available in a standard OR centers may experience a greater time benefit. Improved visu-
(Table 1). Even if all of these materials must be incrementally alization and maneuvering of instruments with the use of the
purchased, the cost is approximately $748 CDN. This is a BCT technique was also observed by the operating surgeon.
1-time setup cost. Once this equipment is in surgical inventory, To complete the diagnostic examination, maximum 1
the ongoing cost of using the BCT technique is approximately surgical assistant generates and maintains the necessary rota-
$65 CDN per surgical case, because most of the materials used tion to visualize all relevant shoulder anatomy, including
are reusable. The phase 4 gel splint has the capacity for limited anterior structures. Throughout the duration of the procedure,

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Techniques in Shoulder & Elbow Surgery  Volume 13, Number 4, December 2012 Beach Chair Traction for Shoulder Arthroscopy

the arm is typically maintained in a neutral position and does the axillary roll was appreciated during the diagnostic exami-
not often require rotation. The amount of traction we apply nation of the shoulder. With the axillary roll removed, the
with the BCT positioning technique (7 to 12 lbs) is consistent majority of the traction force is directed to open the sub-
with that reported in other modified beach chair positioning acromial space during arthroscopic shoulder surgery, which is
descriptions.4,8 This weight can be easily increased or highly beneficial in achieving optimal visualization and safe,
decreased based on the patient’s size, and therefore, objec- efficient, and comfortable clearance for instrumentation
tively titrated to use the least amount of weight necessary to (Fig. 5). Arthroscopic rotator cuff decompressions and repairs
create the appropriate amount of joint space. The improved were selected for this study to highlight the effectiveness of the
lateral distraction and glenohumeral visualization that was BCT technique both inside and outside the joint. Because of a
observed is likely due to the larger lateral force vector created low frequency of exposure, other shoulder procedures includ-
with the use of an axillary roll (Fig. 4). This lateral distraction ing stabilization were not included. With the addition of
pretensions the posterior capsule, promoting controlled, traction to the SBC position, there is an increased potential for
atraumatic entrance into the glenohumeral joint space with the associated neurovascular complications, although we did not
camera trochar.5 However, the use of an axillary roll to create observe any such complications. Beyond this study, we have
this lateral distraction does not seem to be consistently applied used this system for over 2 years now and have yet to
by other authors; although the theory of its benefit was outlined encounter any postoperative neuropraxia after using the com-
more than a decade ago by O’Brien et al5 in their description of bined longitudinal traction/lateral distraction technique.
the adduction distraction maneuver. We believe that the ben- The benefits of BCT may be particularly advantageous
efits associated with the use of an axillary roll justify its routine when shoulder arthroscopy is performed relatively infrequently,
use. The observed increase in glenohumeral space created by with limited surgical assistance, and in teaching institutions when

FIGURE 5. A, Visualization of the subacromial space of a right shoulder from the posterior portal in the standard beach chair position. B,
The same shoulder, with improved visualization of the subacromial space from the posterior portal in the beach chair traction position
without an axillary roll. C, Visualization of the subacromial space from the lateral portal in the standard beach chair position. D, The
same shoulder, with improved visualization of the subacromial space from the lateral portal in the beach chair traction position without
an axillary roll. (Acr indicates acromion; RC, rotator cuff).

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ElMaraghy et al Techniques in Shoulder & Elbow Surgery  Volume 13, Number 4, December 2012

the potential for iatrogenic trauma to articular surfaces and 3. Grant AC, Vical AF, McCarty EC. Arthroscopic approach to posterior
surrounding tissues is higher in the hands of less-experienced shoulder instability. Oper Tech Sports Med. 2007;15:111–115.
surgeons. We are, of course, unable to quantify the improved 4. Hoenecke HR, Fronek J, Hardwick M. The modified beachchair
safety and decreased tissue damage that may have resulted from position for arthroscopic shoulder surgery: the La Jolla beachchair.
improvements in instrumentation clearance. However, as a Arthroscopy. 2004;20:113–115.
supervising surgeon teaching trainees, the senior author feels 5. O’Brien SJ, Gonzalez DM, Wright JM, et al. The adduction distraction
more comfortable allowing less-experienced surgeons to operate maneuver. Arthroscopy. 1997;13:530–532.
when using the BCT technique. Surgeons may also be able to
6. Peruto CM, Ciccotti MG, Cohen SB. Shoulder arthroscopy position-
realize additional time efficiencies and benefit from the stable
ing: lateral decubitus versus beach chair. Arthroscopy. 2009;25:
and predictable supplemental space creation using the BCT
891–896.
positioning technique if operating in an environment where
teaching surgical procedures is not required and shoulder 7. Provencher MT, McIntire ES, Gaston TM, et al. Avoiding complica-
arthroscopies are performed infrequently. tions in shoulder arthroscopy: pearls for lateral decubitus and beach
chair positioning. Tech Shoulder Elbow Surg. 2010;11:1–3.
Our BCT positioning technique is simple, accessible, effi-
cacious, and inexpensive to implement. However, it does have 8. Kim KC, Rhee KJ, Shin HD. Beach-chair lateral traction position
some limitations. BCT remains a customized solution as more using a lateral decubitus distracter in shoulder arthroscopy. Ortho-
standardized commercial versions of this technique do not paedics. 2007;30:1001–1003.
currently exist. The weight system we use is not a true “pulley” 9. Miller RH III. Arthroscopy of upper extremity. In: Crenshaw AH, ed.
system, as the cables attach to weights that hang over a standard Campbell’s Operative Orthopaedics. 8th ed. St. Louis, MO: Mosby-
U-shaped arm bolster, potentially creating friction making Year Book Inc.; 1992:1866–1867.
accurate calibration difficult. The aim of this study was to 10. Rains DD, Rooke GA, Wahl CJ. Pathomechanisms and complications
establish efficacy of the BCT technique; any additional space related to patient positioning and anesthesia during shoulder arthro-
increase provided by the traction and the axillary roll was noted scopy. Arthroscopy. 2011;27:532–541.
through observation and not quantified, as this is dependent on 11. Dippmann C, Winge S, Henning BN. Severe cerebral desaturation
many different variables including patient differences, variants during shoulder arthroscopy in the beach-chair position. Arthroscopy.
in anesthesia, paralysis, and/or tissue creep. A scrub nurse or 2010;26(suppl 1):S148–S150.
surgical assistant is occasionally required to adjust or maintain
12. Murphy GS, Szokol JW, Marymont JH, et al. Cerebral oxygen desa-
the amount of internal or external shoulder rotation required turation events assessed by near-infrared spectroscopy during shoulder
during certain steps of the surgical procedure. Lastly, changes in arthroscopy in the beach chair and lateral decubitus positions.
arm position are somewhat cumbersome if needed repeatedly, Arthroscopy. 2010;111:496–505.
thereby precluding its use as a true shoulder positioning system.
13. Kartus C, Kartus J, Matis N, et al. Long-term independent evaluation
after arthroscopic extra-articular bankart repair with absorbable tacks.
REFERENCES J Bone Joint Surg Am. 2008;90(suppl 2 part 2):262–274.
14. Lafosse L, Brzoska R, Toussaint B, et al. The outcome and structural
1. Baechler MF, Kim DH. Patient positioning for shoulder arthroscopy integrity of arthroscopic rotator cuff repair with use of the double-row
based on variability in lateral acromion morphology. Arthroscopy. suture anchor technique. J Bone Joint Surg Am. 2008;90(suppl 2):
2002;18:547–549. 275–286.
2. Correa MC, Goncalves LBJ, Andrade RP, et al. Beach chair position 15. Kilinc AS, Ebrahimzadeh MH, Lafosse L. Subacromial internal spacer
with instrumental distraction for arthroscopic and open shoulder sur- for rotator cuff tendon repair: “the balloon technique”. Arthroscopy.
geries. J Shoulder Elbow Surg. 2008;17:226–230. 2009;25:921–924.

176 | www.shoulderelbowsurgery.com r 2012 Lippincott Williams & Wilkins