Is There a Preferred Position for Arthroscopic Rotator Cuff Repair?
Dr. Michael Bender and Dr. Brent Morris respond to questions from ICJR about the beach chair versus the lateral decubitus position for patients undergoing arthroscopic surgery to repair a rotator cuff tear.
ICJR: What are the pros and cons of the beach chair and lateral patient positions for arthroscopic rotator cuff repairs?
Michael J. Bender, MD: Rotator cuff tears are one of the most common shoulder problems treated by orthopaedic surgeons. As surgeons have transitioned from open to arthroscopic techniques to treat most shoulder pathology, there has been spirited debate over the superiority of lateral decubitus or beach chair positioning for various procedures. Most surgeons determine patient positioning based on their training and comfort level, but there are some distinct differences between the 2 positions.
Lateral Decubitus Positioning
The patient is placed in the lateral decubitus position on a standard operating room bed with the operative extremity up. A beanbag or other commercial positioner stabilizes the patient; the use of an axillary roll and judicious padding of bony prominences and superficial nerves is crucial to prevent pressure ulcers or nerve complications. A lateral traction device holds the arm in an abducted position, typically with 10 to 15 pounds of traction.
Proponents of the lateral decubitus position cite these benefits:
- Traction increases the space within the subacromial space and the glenohumeral joint, the latter of which may ease the visualization and treatment of labral pathology. [1-3]
- This position allows full access to the shoulder and minimizes any potential mechanical blocks from the bed or head for posterior and superior portals. [3,4]
- Cautery bubbles are less likely to obstruct visualization as they drift laterally out of the field of view, and there is less camera fogging. [3,4]
- The risk of hypotension and cerebral hypoperfusion while under general anesthesia is greatly diminished with the head at the same level as the rest of the body. 
Potential drawbacks of the lateral position include:
- Non-anatomic position
- Higher reported rates of thromboembolic complications 
- Potential difficulty in converting to an open procedure
- Difficulty in doing an exam under anesthesia after the patient is positioned, as the scapula is not stabilized 
General anesthesia with endotracheal tube intubation or a laryngeal mask airway (LMA) is required, as there is more difficult airway access and the potential for fluid extravasation to the neck and airway. [2,7,8] Therefore, lateral positioning is not appropriate for patients who can tolerate only a regional block and sedation.
Neuropraxic injury from traction is one of the most common complications, with reported rates of 10% to 30%. [2,9] This highlights the importance of limiting the weight necessary for traction. Additional neurologic injuries to the axillary and musculocutaneous nerves have been found to be of increased risk for anterior-inferior portals in this position. [8,10]
Beach Chair Positioning
Specialized beds or bed adaptors are used to facilitate positioning the patient in a more upright or seated position (typically 60 to 80) with the hips and knee slightly flexed to relax the nerves and prevent sliding. The posterior aspect of the shoulder should be exposed to the medial aspect of the scapula for full access to the shoulder. A well-padded head support holds the neck in a neutral position and is of paramount importance, as altered neck flexion/extension, rotation, or excessive tilt can have detrimental consequences to both the spinal cord and posterior cerebral circulation through the vertebral arteries. [4,7,11,12] Various commercial arm positioners are available, and they are typically attached to the bed to minimize the need for assistance for arm holding.
Surgeons who advocate for beach chair positioning appreciate:
- The more anatomic positioning
- The ease of exam under anesthesia
- The convertibility to an open procedure (which was likely more pertinent as surgeons were still transitioning from open to arthroscopic techniques) 
Anesthesiologists have better airway access, as they can convert to a supine position easily, and regional anesthesia with sedation is better tolerated by patients who cannot have a general anesthetic. [2,4,7,8] Improved arm positioners can facilitate a wider variety of arm positions that may be helpful for certain procedures. Neurologic injuries from traction or portal placement also appear to be reduced with this position. [2,7,9]
The most glaring and discussed drawback of beach chair positioning is the risk of decreased cerebral perfusion in the upright position when hypotensive anesthesia is performed to improve arthroscopic visualization and minimize bleeding. [2,7,12-15] Although extremely rare, the consequences of stroke, brain death, or even more minor neurologic sequelae can be devastating.  Additional concerns over neck positioning, mechanical blocks from the bed or patient’s head, and ease of addressing labral pathology are other potential downsides. [1,3,4,7,11]
Other potential differences, such as efficiency and ease of setup, are claimed by both sides, but may be more dependent on staff and surgical team familiarity with the position than the superiority of one position over the other. [2,7,9] The need for additional assistants with either position also may depend more on the particular procedure and techniques utilized. Lastly, the initial upfront overhead costs for specialized beds and arm positioners for the beach chair position has been used as an argument against it, but the impact of the cost may depend on how frequently the equipment is utilized. [2,7]
ICJR: Does the literature show a preference for either position?
Brent J. Morris, MD: Although there has been much debate over superiority in positioning, the majority of the literature on the topic focuses on treating labral pathology or the complications related to positioning, anesthesia, and portal placement. To date, there is little comparison of surgical outcomes for rotator cuff repairs done in the lateral versus the beach chair position.
The best assistance the literature can provide is which patients are at increased risk of complications attributed to a position and how to prevent complications from occurring. The most written-about issue by far is the concern for cerebral hypoperfusion in the beach chair position due to its devastating, yet rare, consequences. [5,7,11-20] The exact incidence of cerebral hypoperfusion is unknown, as most are documented through case reports or based on surveys of shoulder surgeons, but all reported cases of cerebral hypoperfusion associated with arthroscopic rotator cuff repair have occurred in the beach chair position. [5,7,16]
Patients who are awake can increase their systemic vascular resistance to maintain cerebral blood flow when sitting upright, but patients under general anesthesia have an impaired sympathetic nervous system response, and vasodilation from the anesthetics creates a risk for hypoperfusion in upright patients. [5,11] Brachial pressure measurements will also be different from cerebral measurements due to the hydrostatic pressure differences from the arm to the head. [11,12,18] Current anesthesia guidelines are to keep systolic blood pressure (SBP) at more than 90 mm Hg and limit reduction of SBP and mean arterial pressures (MAP) to less than 20% of baseline levels. However, recent studies have demonstrated that lower SPB and MAP levels may be safe, without increased risk of electroencephalography changes or cerebral deoxygenation events (CDE), defined as a more than 20% decrease in cerebral oxygenation saturation from baseline. [5,7,8,13,21]
Cerebral deoxygenation events have been used as a surrogate marker for possible ischemia, as they have been correlated with cerebral ischemia and cognitive abnormalities postoperatively.  Murphy et al  demonstrated a much higher incidence of CDEs in the beach chair position than in the lateral decubitus position (80.3% vs 0%), however, no neurologic deficits were found in either group. Koh et al  later demonstrated that the risk of CDEs in the beach chair position could be greatly decreased when a regional block with sedation was utilized rather than a general anesthetic (56.7% vs 0%). Aguirre et al  confirmed the findings of fewer CDEs with a regional block and demonstrated improved neurobehavioral testing at 24 hours after surgery compared with general anesthesia. Elevated body mass index (BMI) was found to be one of the highest risk factors for CDEs by Salazar et al. 
All efforts should be made to prevent this complication, which starts with recognizing high-risk patients with elevated BMI, labile blood pressures, and stroke risk factors. [11,12,15] Considerations in these patients should be made for cerebral oximetry, regional anesthesia, and use of cuff measurements on the brachium or via an arterial line to differentiate the measured brachial pressure from that of the brain. [5,11-13,15,17] Surgeons cognizant of these factors can make an already low-risk surgical position even safer.
ICJR: What is your preferred patient position for arthroscopic rotator cuff repair and why?
Dr. Morris: Although many surgeons use one patient position exclusively for all arthroscopic procedures, our preference is to utilize lateral decubitus positioning to address isolated labral pathology and beach chair positioning for rotator cuff repairs and nearly all other arthroscopic shoulder surgeries. Rotator cuff repairs are performed with an interscalene block, although a light general anesthetic is often used in conjunction with regional anesthesia at the discretion of the anesthesiologist. Patients are positioned approximately 80 upright relative to the floor, with careful head/neck positioning. A Trimano arm positioner (Arthrex, Naples, Florida) is typically used.
As is the case with most surgeons, our preference for beach chair positioning in due in large part to being trained on this position for rotator cuff repair surgery at our institution. It also means our surgical team is much more familiar with placing patients in the beach chair position than in the lateral decubitus position, which makes setup and surgery more efficient. The beach chair position with modern arm holders allows the arm to be positioned precisely and in more variable positions than the lateral position, in our experience, which can help with ease of arthroscopic subscapularis repairs, arthroscopic bicep tenodesis, and lateral row anchor placement. The ability to perform and repeat an exam under anesthesia, especially after any capsular release has been performed, is easier in the beach chair position without having to take the arm out of a traction device. Although converting from an arthroscopic to an open procedure for any reason is rare in our practice, this could be considered by some as an added benefit of the beach chair position.
Although there is currently no gold standard position for arthroscopic rotator cuff repair, the rare but potential complications of both positions must be recognized. Surgeon should use the position they believe will provide the best chance at an excellent patient outcome, while being diligent to avoid preventable complications.
About the Experts
Michael J. Bender, MD, is a Shoulder and Elbow Fellow at Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas, as part of the Texas Education and Research Foundation for Shoulder and Elbow Research, Inc. (TERFSES) Shoulder and Elbow Fellowship. Brent J. Morris, MD, is a Shoulder and Elbow Surgeon at Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas, and Co-Fellowship Director for the TERFSES Shoulder and Elbow Fellowship.
The authors have no disclosures relevant to this article.
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