INTRODUCTION

Shoulder arthroscopy is currently one of the mainstayprocedures for the treatment and diagnosis of shoulderdisorders [1]. With an estimate of greater than 250,000shoulder arthroscopies annually, there has been an in-creasing interest in this procedure since the early 2000s[2]. Shoulder arthroscopy is typically performed ineither the beach chair position or the lateral decubitusposition. The purpose of this article is to examine eachof these positions, and shed light on the advantages anddisadvantages each offers. Even though there is no con-sensus regarding a superior positioning, and the choice isusually determined by surgeon’s experience and prefer-ence [3,4], and occasionally by the pathology to beaddressed [5].

The two positions require the same preparations priorto the procedure, including shoulder marking and the useof anesthesia (general anesthesia with the possibility ofan interscalene nerve block) [6]. The operating room set-up required is the same in both positions, requiring anarthroscopy tower, instrument tower, fluid managementand suction equipment opposite to the side where thesurgeon and assistants are standing (Figure 1). The anes-thesia staff and equipment are placed at the head of thesurgical table, and a back table with surgical tools behindthe surgeon, assistant, and surgical technician [7].

BEACH CHAIR POSITION

It is estimated that around two-thirds of more than400,000 shoulder arthroscopies are performed in a beachchair position [8]. The patient is put on a “beach chair”table or a standard operating room table with head, neckand torso supported with straps in a neutral position. Thepatient is positioned with the hips flexed around 45º; thisprevents the patient from sliding down the operating

Lebanese Medical Journal 2017 • Volume 65 (3) 157

OORRTTHHOOPPAAEEDDIICCSSLATERAL DECUBITUS OR BEACH CHAIRA REVIEW OF SHOULDER ARTHROSCOPY POSITIONShttp://www.lebanesemedicaljournal.org/articles/65-3/review1.pdf

Majd MARRACHE1, Said SAGHIEH2, Hasan BAYDOUN2*

Marrache M, Saghieh S, Baydoun H. Lateral decubitus orbeach chair: A review of shoulder arthroscopy positions. J MedLiban 2017 ; 65 (3) : 157-160.

Marrache M, Saghieh S, Baydoun H. Décubitus latéral oubeach chair: Une critique des positions d’arthroscopie del’épaule. J Med Liban 2017 ; 65 (3) : 157-160.

ABSTRACT • Shoulder arthroscopy is currently one of themainstay procedures for the treatment and diagnosis ofshoulder disorders. Shoulder arthroscopy is typically per-formed in either the beach chair position or the lateral decu-bitus position. In this article, we discuss the advantages anddisadvantages of each position. Of note, there currently isno consensus regarding a preferred positioning. Both thelateral decubitus and the beach chair position require thesame preparations prior to the procedure. The advantagesof the beach chair position are numerous, the most signifi-cant of which is the lower risk of neurovascular trauma andan easier conversion to the open approach. Conversely, themain disadvantage of this position is the risk of cerebralhypoperfusion. In regard to the lateral decubitus position,the main advantages are the lower recurrence rates and abetter visualization of labral tears. The disadvantages en-tail an increase risk of neurovascular injury among others.This article will also briefly examine a third position, thesupine position, which was recently described to combinethe advantages of both the lateral decubitus and beach chairwith minimal disadvantages.

Keywords: shoulder arthroscopy; beach chair; lateraldecubitus

RÉSUMÉ • L’arthroscopie de l’épaule est actuellement l’unedes principales procédures pour le traitement et le diagnosticdes pathologies de l’épaule. L’arthroscopie de l’épaule est géné-ralement effectuée soit dans la position ‘beach-chair’, c’est-à-dire en position semi-assise, soit en décubitus latéral. Dans leprésent article, nous discutons les avantages et les inconvé-nients de chaque position. Il est à noter qu’il n’existe actuelle-ment aucun consensus quant à un positionnement préféré. Lesdeux positions, décubitus latéral et beach-chair, exigent lesmêmes préparations avant l’intervention. Les avantages de laposition beach-chair sont nombreux, les plus importants étant lerisque diminué de traumatisme neurovasculaire et une conver-sion plus facile à l’approche ouverte. À l’inverse, le principal in-convénient est le risque d’hypoperfusion cérébrale. En ce quiconcerne le décubitus latéral, les principaux avantages sont unrisque de récurrence diminué et une meilleure visualisation desdéchirures labrales. Les inconvénients entraînent entre autresun risque élevé de blessures neurovasculaires. Le présent articleétudiera brièvement une troisième position, la position couchée,récemment décrite comme combinant des avantages des posi-tions décubitus latéral et beach-chair, et ce avec un minimumd’inconvénients.

Mots-clés: arthroscopie de l’épaule, beach chair, décubituslatéral

1Faculty of Medicine, M4 Student, American University ofBeirut, Lebanon.

2American University of Beirut Medical Center (AUBMC),Department of Orthopeadic Surgery.

*Corresponding author: Hasan Baydoun, MD. e-mail: hasanbaydoun@gmail.com

table. The knees are flexed around 30º; this helps relaxthe sciatic nerve [9]. The patient is then moved to a 10ºto 15º Trendelenburg position, achieving the final up-right beach chair position. A strap is placed around thelegs and abdomen to secure the patient. All pressurepoints are padded and the eyes and head are protected(Figure 2) [1, 4, 10].

The advantages of the beach chair position are numer-ous. Notably, the beach chair position is relatively safewith regards to incidence of neurovascular injuries [10].The risk of injury of the musculocutaneous nerve and thecephalic vein injury is diminished by avoiding the vul-nerable position when establishing an antero-inferiorapproach to the shoulder [11,4]. Also, the position placesless strain on the brachial plexus since no traction is usedto elevate the shoulder [12-13].

Another benefit of the beach chair position is that itallows an easier conversion to an open approach [1].This is especially important to beginner arthroscopists,who can proceed to an open technique without the needto reposition. The approach also allows the surgeon toapproach the anatomy in the same perspective, withoutthe need to reorient themselves.

The most notable disadvantage of the procedure is ce-rebral hypoperfusion, which can have devastating conse-quences [14-15]. Although rare, this complication canresult from the combination of an upright position andhypotension [13]. However, some studies have shownpatients in the beach chair position receiving regionalanesthesia of an interscalene nerve block with sedation,rather than general anesthesia, had close to no cerebraldesaturation [16, 10]. Moreover, placing the patient in asloppy beach chair, as opposed to being upright, furtherdiminishes this effect. Other cases in the literature havereported that the hyperextension and tilt positioning of

158 Lebanese Medical Journal 2017 • Volume 65 (3) M. MARRACHE et al. – Beach chair or lateral decubitus?

FIGURE 2. Beach chair position.

FIGURE 1. Operating room set-up

Anesthesia Machine

Arthroscopy Tower

InstrumentTower

Fluids&

Suction

Operating Table

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Surg

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Back

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M. MARRACHE et al. – Beach chair or lateral decubitus? Lebanese Medical Journal 2017 • Volume 65 (3) 159

the head in this position causes a decrease in vertebralblood flow, which can lead to infarcts [14]. Yet anotherdisadvantage to the beach chair position is the expenseof the equipment required, estimated at $12,000, to placethe patient in the position, requiring almost double thecost of implementing the lateral decubitus position,which is approximately $5,000 [4].

LATERAL DECUBITUS POSITION

In the lateral decubitus position, the patient is placedlaterally on the nonoperative shoulder with the extrem-ity being operated on exposed. The patient is stabilizedby a bean bag or other stabilizing devices. Straps areplaced around the chest and hips to ensure stabilityduring the procedure. Pressure points are protected, aswell as the eyes and face. An axillary roll placed underthe chest is used to protect neurovascular structures.The operative extremity is placed into position using atraction sleeve connected to a traction device. This willexpose the joint space and allow better visualization ofthe joint.

The traction device is a pulley system connected toweights, usually around 15 kilograms, although itmay vary by the surgeon’s preference. These pulleyscan be adjusted to abduct and forward flex the shoulder. (Figure 4).

There are several advantages to performing shoulderarthroscopy in a lateral decubitus position. Those in-

clude a lesser risk for cerebral hypoperfusion, a largeraccess to the glenohumeral joint and lower recurrencerates when addressing arthroscopic shoulder instabilities[5].

One of the major advantages of performing shoulderarthroscopy in a lateral decubitus position is the reducedrisk of cerebral hypoperfusion and ischemia. The head ispositioned at the same level of the body using padding, andthe neck position is neutral with the body. This overalldecreases the risk of devastating decrease in cerebral per-fusion and consequently desaturation. Moerman et al.reported a decrease in 20% of cerebral oxygen saturationin 80% of those patients undergoing shoulder arthrosco-py in the beach chair position as opposed to the lateraldecubitus [17]. Moreover, the position provides an easierand larger access to the glenohumeral joint and subacro-mial space. The traction placed on the shoulder joint alsoallows for better visualization of labral tears [6]. Intra-articular visualization of labral tears is facilitated by thelateral traction on the humerus. Furthermore, the choiceof the lateral decubitus position could result in betteroutcomes when addressing labral pathology [5]. A meta-regression analysis studying around 4000 shoulder arthro-scopies in 2014 revealed lower recurrence rates witharthroscopic anterior shoulder stabilization done in thelateral decubitus position compared to the beach chairposition [5].

Even though lateral decubitus position offers severaladvantages, it also has its own set of drawbacks. Oper-ating room time in the lateral decubitus position is ar-guably much longer, and requires assistance. The posi-tion lacks flexibility whenever it is necessary to resort to

FIGURE 3. Advantages and disadvantagesof the beach chair position for shoulder arthroscopy.

FIGURE 4. Lateral decubitus position.

Advantages

Less risk of neurovascular

trauma

Lesss traction, less brachial plexus strain

Easier converstion to open approach

Decrease surgical time

Disadvantages

Hypoperfursion

Cost

160 Lebanese Medical Journal 2017 • Volume 65 (3) M. MARRACHE et al. – Beach chair or lateral decubitus?

an open procedure. When open conversion is required,the surgeon is required to bring the patient back into asupine, and then a beach chair position to approach theshoulder posteriorly, or into a prone position to approachthe shoulder posteriorly. The lateral position also limitsthe utility of regional anesthesia, and necessitates the useof general anesthesia. However, the most serious conse-quence of this position is the increased risk of neurovas-cular injury [18]. Brachial plexus neuropraxias havebeen reported as a major complication, this is resultingfrom the increase in strain on the brachial plexus causedby intra-operative traction [12].

For surgeons who are accustomed to a supine openapproach, transitioning from a lateral decubitus positionis more difficult and disorienting. Furthermore, rotatingthe arm into the lateral decubitus position will affect theease of approaching rotator cuff tears. The patient is po-sitioned at a 90º angle orientation relative to the supineand will need repositioning.

Even though the most common positions used inshoulder arthroscopy are the beach chair and lateral de-cubitus positions, more recently a ‘supine’ position intro-duced by Lamsumang et al. demonstrates some advan-tages of both positions and less of the disadvantages.The patient is positioned supinely in the reverse position

on the table. The leg plate on the operating side is re-moved to make space and the head is maintained in neu-tral position. The arm is then strapped to a traction deviceto position the shoulder in a 45º of forward flexion and30º of abduction. The initiation of arthroscopy is with aposterior portal slightly lateral to the glenohumeral jointline, an anterior-superior portal and anterior-inferior por-tal can then be made. The remainder of the procedure isthe same as in the lateral decubitus and the beach chairpositions [19].

This position is described to combine the advantagesof both the lateral decubitus and beach chair with mini-mal disadvantage. The supine position provides betteraccess to the joint, while having the patient’s head andoperating table far from the surgical field and the armnot hanging in the way. The supine position also allowseasier conversion to the open procedure without reposi-tioning or redraping. Lastly, it entails an easier setupthan the alternative positions [19].

CONCLUSION

Shoulder arthroscopy is a common procedure indicatedfor diagnosis to treatment of conditions ranging fromintra-articular to extra-articular pathology. Shoulder ar-throscopy continues to be increasingly popular as sur-geons have become more comfortable with the treatmentof more complex shoulder problems arthroscopically.Although both the lateral decubitus and beach chair posi-tions for shoulder arthroscopy procedures have respec-tive advantages and disadvantages (Figures 3 & 5), it isdifficult to determine a superior method. Furthermore, therecent introduction of the supine position suggests thatcurrent techniques are still being challenged and improved.

Each position requires certain indications, precau-tions, and surgeon preference. The major disadvantageof both positions continues to be neurovascular injury,even though it is rare with both positions, and at timesavoidable with proper patient safety precautions. Currentliterature comparing the different positions remains lim-ited. Further research on long-term outcomes is requiredto adequately compare the rate of complications and suc-cesses, and recurrence between the two positions.

ACKNOWLEDGEMENT

We thank Dr. Muhyeddine Taki and Mr. David Habib forthe images.

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FIGURE 5. Advantages and disadvantagesof the lateral decubitus for shoulder arthroscopy.

Advantages

Less risk of cerebral

hypoperfusion

Lower recurrence rates

increase access to glenohumeral joint

and subacromial space

Better visualization of

labral tears

Disadvantages

Harder conversion to open procedure

Increase risk of neurovascular

injury

Regional anesthesia not well tolerated

M. MARRACHE et al. – Beach chair or lateral decubitus? Lebanese Medical Journal 2017 • Volume 65 (3) 161

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