Beach Chair Position Research Articles

Effect of a Preoperative Subacromial Epinephrine Injection on Visualization During Shoulder Arthroscopic Surgery: A Randomized Controlled Trial.

The addition of epinephrine to arthroscopic irrigation fluid has been shown to improve surgeon-rated visual clarity during shoulder arthroscopic surgery. Subacromial injections of epinephrine are also used for this purpose. To assess the influence of a preoperative subacromial epinephrine injection on surgeon visualization during subacromial shoulder arthroscopic surgery. It was hypothesized that the epinephrine injection would improve surgeon-rated visual clarity. Randomized controlled trial; Level of evidence, 1. A double-blind randomized controlled trial including adult patients undergoing shoulder arthroscopic surgery in the beach-chair position requiring visualization of the subacromial space was performed. Patients in the epinephrine group (n = 30) received a preoperative subacromial injection of bupivacaine and epinephrine, and those in the control group (n = 30) received a preoperative subacromial injection of bupivacaine. Epinephrine was added to the first 10 L of arthroscopic irrigation fluid in all patients. The primary outcome was surgeon-rated visual clarity throughout the procedure that was recorded at the end of the procedure using a visual analog scale (VAS) scored from 0 (worst) to 10 (best). Secondary outcomes included an increase in pump pressure during the procedure, total operative time, and the intraoperative use of blood pressure-modulating medications. Rotator cuff repair was performed in 88.3% of patients (25/30 epinephrine; 28/30 control), with multiple procedures performed in 85.0% of patients (23/30 epinephrine; 27/30 control). The VAS score for visual clarity was slightly better in the epinephrine group compared with the control group, although the difference was neither statistically nor clinically significant (8.3 ± 1.4 vs 7.5 ± 1.8, respectively; P = .09). There was no difference between the epinephrine and control groups in the need for an increase in pump pressure to improve visualization (8/30 [26.7%] vs 7/30 [23.3%], respectively; P > .99), total operative time (62.0 ± 19.4 vs 64.0 ± 30.1 minutes, respectively; P = .90), or the intraoperative use of blood pressure-modulating medications (20/30 [66.7%] vs 17/30 [56.7%], respectively; P = .60). There were no perioperative adverse events in either group. The addition of a subacromial epinephrine injection before shoulder arthroscopic surgery resulted in a small improvement in visual clarity that was neither statistically nor clinically significant, with no adverse effects reported in this study. NCT05244525 (ClinicalTrials.gov).

Arthroscopic Mumford Procedure for AC Joint Arthritis

Background: Acromioclavicular (AC) joint arthritis is a common cause of shoulder pain in young patients. Management has been focused on relieving pain mainly with conservative nonsurgical procedures such as corticoid injections, physical therapy and even, recently, orthobiological interventions with platelet-rich plasma and hyaluronic acid injections. However, failed conservative management opens the door to surgical interventions such as the arthroscopic distal third of the clavicle resection. Indications: Patients submitted to this surgery must have a confirmed diagnosis of an arthritic, painful AC joint that has not been properly responding to nonoperative management. Technique Description: The surgical procedure is done in the beach chair position with standard arthroscopic portals. After a proper intraarticular evaluation of the structures and ruling out any other causes of pain, the surgeon passes to the subacromial space. Identification of the AC joint is made by following the coracoacromial ligament medial and with manipulation of the clavicle from the patient's skin. Debridement should start by releasing the anterior and posterior ligaments to allow for proper visualization of the articulation. A bur or a 5.5-mm shaver is used to start resection of the distal third of the clavicle under visualization and with care to not create a vault. The procedure is considered done when a smooth articular surface is visualized and with at least 5 mm of space between the clavicle and the acromion. Results: The proposed technique, which is a variant of the classic distal clavicle excision, has shown improved functional outcomes with reproducible postoperative scores and low complications rates in the setting of patients with isolated AC joint arthritis. Conclusion: Surgical management of the painful, arthritic AC joint has been evolving alongside with the history of shoulder arthroscopy; the proposed arthroscopic approach is an easy and effective way of freeing the patient of pain and discomfort with quick return to activities and sports. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Comparing Access to Engaging Hill-Sachs Lesions Between the Modified Posterior Deltoid Split Approach and Standard Deltopectoral Approach for Bone Grafting.

Hill-Sachs lesions are common after shoulder instability, and treatment options vary but include remplissage or implantation of structural bone graft. Large Hill-Sachs lesions not addressed by remplissage are challenging to manage and may frequently require an open surgical approach for bone filling treatment options. The optimal approach to maximize visualization of the humeral head during these procedures remains unclear. The purpose of this study was to compare the area of the humeral head accessed using a modified posterior deltoid split approach versus a standard deltopectoral approach without surgical dislocation, with particular attention to access of engaging Hill-Sachs lesions for the purpose of bone grafting in the setting of anterior shoulder instability. It was hypothesized that both approaches would provide equal access to a simulated Hill-Sachs lesion. Controlled laboratory study. Four human cadaveric shoulders were mounted in the beach-chair position. The modified posterior deltoid split approach and nonextensile deltopectoral approaches were performed. A typical Hill-Sachs lesion was simulated on the humeri. The percentage of the total surface area of the humeral head that was accessed, including access to the simulated Hill-Sachs lesion, was mapped using 3-dimensional digitizing software. The deltopectoral approach provided 45% ± 15.2% access (range, 24% to 58%) to the humeral head versus 22.2% ± 6.1% (range, 17% to 30%) for the modified posterior deltoid split approach (P = .057). The modified posterior deltoid split approach enabled 100% access of the simulated Hill-Sachs lesion compared with 0% for the nonextensile deltopectoral approach. The angle of access to the articular surface was direct and perpendicular with the modified posterior deltoid split approach. The overall surface area of the humeral head accessed via the modified posterior deltoid split approach was less compared with the deltopectoral approach; however, the entire area of a typical Hill-Sachs lesion was able to be accessed from the modified posterior deltoid split approach, whereas this area was not well visualized from the standard deltopectoral approach. The modified posterior deltoid split approach provided sufficient access to the humeral head for the purposes of grafting an engaging Hill-Sachs lesion in the setting of anterior shoulder instability.

Arthroscopic Remplissage Before Bankart Repair With All-Suture Anchor Mattress Fixation in the Beach-Chair Position

A common procedure for treatment of Hill-Sachs lesions in the setting of anterior shoulder instability is arthroscopic remplissage. Remplissage consists of using the posterior capsule and infraspinatus tendon to fill the Hill-Sachs lesion and convert it into an extra-articular defect. Previous versions of this technique have not specified the timing in which remplissage and Bankart repair occur and have been performed with the patient in the lateral decubitus position. In this Technical Note, we describe our technique where we perform the remplissage before Bankart repair using all-suture anchor mattress fixation with the patient in the beach-chair position. By performing the remplissage before Bankart repair, the shoulder is reduced to allow for easier execution of the remplissage and reduce difficulties that might prevent its completion if done after Bankart repair. Further, by completing remplissage before Bankart repair in the beach-chair position, the humeral head is moved posteriorly with the cuff to allow for better access for the following labral repair and allows for the standardization between arthroscopic and open shoulder instability management.

Results of transosseous suture fixation in four-part valgus impacted fractures of the proximal humerus

BackgroundThe osteonecrosis ratio in valgus impacted fractures of the proximal humerus is low (<10 %), giving osteosynthesis all its meaning. However, the optimal fixation technique remains controversial. After recentering the humeral head, osteosuture is stable enough to allow bone healing in an adequate position as well as a good long-term shoulder functionality. MethodsOur cohort included 22 patients with a mean age of 65 (28–83). Patients were placed in a beach-chair position. Surgical exposure was done through an anterolateral, transdeltoid approach. Stay sutures were placed on both tuberosities. Elevation of the humeral head was obtained for 9 patients using iliac crest bone graft, for 7 patients using bone substitutes, for 6 without any graft needed. Both tuberosities were approximated and tied together using two horizontal non-absorbable double-threaded sutures. The whole head was also tied to the humeral metaphysis by cerclage wiring using the same suture. Patients were immobilized in a sling for 4 weeks with no passive or active mobilization; then began rehabilitation starting with passive and active-assisted mobilization. Functional outcome was assessed with the Constant score. Radiographic follow-up was used for fracture healing and osteonecrosis signs. ResultsAll fractures united within the first 3 months. One patient had radiographic signs of osteonecrosis and one had a secondary displaced fracture without osteonecrosis. At an average follow-up of 35 months, the median Constant score was 83.7 % (63–100) in comparison to the uninjured side. DiscussionA preserved posteromedial periosteal hinge in a valgus impacted fracture of the proximal humerus is key to the success of osteosuture. This hinge provides mechanical stability to the humeral head once elevated, as well as blood-supply from the branches of the posterior circumflex humeral artery. Computed Tomography with Three-Dimensional reconstructed images allow for a precise analysis of this hinge as well as the vascularity of the humeral head. Osteosuture being a minimally invasive surgical procedure plays a predominant role in sparing the remaining vascularization of the humeral head. ConclusionOsteosuture in four-part valgus impacted fractures of the proximal humerus is a minimally invasive procedure as well as a reliable technique yielding good long-term results.

Dexmedetomidine vs. Propofol: Haemodynamic Changes in Conscious Sedation in Arthroscopic Shoulder Surgery in the Beach Chair Position: A Randomized Control Trial

Background: Interscalene brachial plexus block (ISB) combined with conscious sedation is a viable alternative to general anaesthesia for arthroscopic shoulder surgery in the beach chair position. The purpose of the trial was to compare the haemodynamic instability and safety of Dexmedetomidine vs Propofol for conscious sedation in arthroscopic shoulder surgery in the beach chair position. Method: A single-blinded prospective randomized trial was conducted in 56 patients randomly allocated into Dexmedetomidine and Propofol groups for conscious sedation following ISB placement. The primary outcome was to measure intraoperative haemodynamic variations (systolic blood pressure, mean arterial pressure, heart rate) in the two groups maintaining adequate conscious sedation during arthroscopic shoulder surgery in the beach chair position. Results: In the dexmedetomidine group a significantly higher percentage of systolic blood pressure (21.86 𝑣𝑠 10.81%, p = 0.001, 𝑑 = 1.05) and a higher percentage heart rate (18.52 vs 9.02%, p = 0.002, 𝑑 = .98) drop from baseline measurements was noted. A large (d ≥ 0.8) Cohen’s effect size suggested the high practical significance of the finding. Perioperative hypotensive (f=19, p&lt;0.001) and bradycardic (f=21, p=0.003) episodes were significantly more frequent in the dexmedetomidine group. The propofol group had a greater incidence of airway complications requiring intervention (f=6 vs f=0, p=.023). Conclusion: Dexmedetomidine leads to significant blood pressure and heart rate reductions from baseline values in the beach chair position providing controlled hypotension and has minimal airway complications in patients undergoing arthroscopic shoulder surgery in the beach chair position under ISB and conscious sedation compared to Propofol.

Cementless Long-Stem Reverse Total Shoulder Arthroplasty as Primary Treatment for Metadiaphyseal Humeral Shaft Fractures.

The use of cementless diaphysis-fitting stems has been shown to be an effective treatment option for cases of metadiaphyseal humeral fracture. Complex metadiaphyseal fractures are those that extend below the surgical neck into the diaphysis, which can compromise the metaphyseal fixation of typical arthroplasty designs. The presently described surgical technique circumvents the potential risks associated with the use of cement while also permitting the treatment of common concomitant pathologies, such as arthritis and rotator cuff tendinopathy. Evidence supports the efficacy of this technique, showcasing consistent rates of healing, pain relief, and functional recovery, as well as acceptable complication rates compared with alternative surgical options. The surgical procedure is performed with the patient in a modified beach chair position. A deltopectoral approach is utilized in order to expose the humerus and glenoid. In cases in which the tuberosity is fractured, it is carefully tagged for subsequent repair. The metadiaphyseal extension of the fracture is exposed, and reduction is performed with cerclage cable augmentation as needed. When direct reduction proves challenging, the humeral prosthesis is utilized to aid in reduction. Full-length humeral radiographs and a humeral sounder are utilized to guide the placement of a trial prosthesis, ensuring that the stem spans 2 canal diameters past the fracture and restores the appropriate humeral length. The medullary stem is utilized as support for fracture fragment reduction, with use of a combination of bone stitching and cerclage cables as required. Fractures with compromised proximal humeral bone stock can be further augmented with extramedullary strut allografts and cerclage cables. The allograft strut fixation acts as a neutralization plate to maintain rotational control. The joint is reduced, and fixation of the subscapularis and tuberosity is achieved with use of a transosseous suture technique. This technique combines the use of arthroplasty as well as standard osteosynthesis principles to treat complex metadiaphyseal humerus fractures. Nonoperative treatment may be indicated in a primary setting and represents a multifactorial patient-specific decision. Other surgical options include open reduction with internal fixation with plates or an intramedullary humeral nail, and cemented long-stem arthroplasty. If the fracture is too distal and the surgeon is unable to achieve a length of 2 canal diameters for distal fixation, alternative treatment strategies such as cementation may be required. This procedure is most often performed in elderly patients with osteoporosis, who often also have comminuted fracture patterns and conditions such as glenohumeral arthritis or chronic rotator cuff pathology1,5,6,13,15. Whereas open reduction and internal fixation (ORIF) can be effective in younger patients, it poses higher risks of complications in patients with osteoporosis1,3,9,14-16. Neither ORIF nor intramedullary nailing addresses concurrent pathologies. Another alternative technique involves the use of a cemented stem; however, a cementless approach eliminates theoretical risks of cement use, allows easier revisions, and achieves comparable outcomes9,16,20. In summary, cementless long-stem RTSA offers consistent healing rates, satisfactory outcomes, and favorable results. Cementless long-stem reverse total shoulder arthroplasty (RTSA) is a viable alternative for elderly patients with metadiaphyseal proximal humeral fractures. This technique shows consistent healing rates, pain relief, shoulder function restoration, and an acceptable complication rate. In a study of 14 patients who underwent cementless long-stem RTSA from September 2017 to August 2020, all patients showed improved outcomes and radiographic evidence of union at an average of 13 months postoperatively. Minor complications have been reported, such as transient neuropathy, tuberosity nonunion, and humeral stress shielding. This technique is optimal for elderly patients with osteoporotic bone, comminuted fractures, glenohumeral arthritis, and/or rotator cuff pathology.Long comminuted fractures require bridging fixation, spanning 2 canal diameters beyond the fracture site.Patients with compromised proximal humeral bone stock may require allograft strut augmentation.The surgical principle integrates standard arthroplasty for joint length restoration, a relative fracture stability concept by spanning complex fracture segments, and an absolute stability concept by direct fragment alignment. RTSA = reverse total shoulder arthroplastyIMN = intramedullary nailORIF = open reduction and internal fixationAVN = avascular necrosisAP = anteroposteriorCT = computed topographyTSA = total shoulder arthroplastyXR = plain radiographsFU = follow-upSST = simple shoulder testASES = American Shoulder and Elbow SurgeonsDASH = Disabilities of the Arm, Shoulder and HandPROM = patient-reported outcome measuresROM = range of motion.

Predictive Value of Ultrasound-Measured Quadriceps Depth and Frailty Status for Hypotension in Older Patients Undergoing Reverse Total Shoulder Arthroplasty in the Beach Chair Position under General Anesthesia.

The beach chair position (BCP) is widely used in shoulder surgery; however, it frequently leads to hypotension. Hypotension in BCP is prevalent among older patients who are at risk of secondary complications such as ischemic injuries. Therefore, this prospective study aimed to investigate the association and predictive value of frailty, as assessed by ultrasound-measured quadriceps depth and questionnaire, in patients aged ≥65 years undergoing elective shoulder surgery under general anesthesia. A multivariable logistic regression analysis was performed to identify independent risk factors for hypotension in BCP under general anesthesia. Receiver operating characteristic curves were constructed to assess the predictive values of various parameters. The results indicated that a quadriceps depth < 2.3 cm and BCP for an extended period significantly increased the risk of hypotension. The combined consideration of quadriceps depth < 2.3 cm and frailty demonstrated markedly superior predictive power compared with each factor individually. In conclusion, the study findings facilitate the screening and identification of risk factors for older patients undergoing surgery in BCP, thereby enhancing perioperative management.

The incidence and decompression rates of median and ulnar neuropathies following shoulder surgery

BackgroundUpper extremity peripheral neuropathy is a known, but uncommon complication that can occur after shoulder surgery. The incidence rate is well documented, and most of these cases historically have been treated conservatively. However, we hypothesize peripheral compression neuropathy requires a much higher need for surgical decompression than originally reported. The purpose of this study was to evaluate the incidence, decompression rates, and prognostic factors for developing median and ulnar neuropathies following shoulder surgery. MethodsA retrospective chart review was performed examining patients who underwent open and arthroscopic shoulder surgery from a multi-surgeon, single-institution database. Perioperative data and functional outcomes were recorded. Symptom resolution was assessed with both conservative and surgical management of compression peripheral neuropathy. Further analysis was made to compare open and arthroscopic procedures, the type of neuropathy developed, and EMG severity. ResultsThe incidence rates of compression peripheral neuropathy following open arthroplasty and arthroscopic procedures was 1.80% (31/1722) and 0.54% (44/8150), respectively. 73.33% (55/75) of patients developed ipsilateral disease, while 20.00% (15/75) of patients had bilateral disease.Amongst the 75 included patients, there were 99 cases of neuropathy. Carpal tunnel syndrome (CTS) was more common than cubital tunnel syndrome (CuTS), comprising 61.61% (61/99) cases of neuropathy. 12.00% (9/75) of patients developed both CTS and CuTS.Four patients were lost to follow-up. Decompression surgery was performed for 36.84% (35/95) cases of neuropathy with >90% obtaining symptom resolution with surgery. 63.16% (60/95) cases of neuropathy were managed conservatively, 71.67% (43/60) of which had persistent symptoms.When comparing arthroscopic versus open procedures, patients who underwent open procedures were significantly older (68.62 vs. 49.78 years, p < .001) and developed peripheral neuropathy significantly faster after the index procedure (87.24 vs. 125.58 days, p = .008).EMG severity did not correlate with decompression rates or symptom resolution. There were no differences in the subgroup analyses between beach chair and lateral positioning in regard to the type of neuropathy, laterality of symptoms, and/or treatment received. ConclusionsThe overall incidence of peripheral neuropathy after shoulder surgery was 0.76% (75/9872). The development of peripheral neuropathy is multifactorial, with older patients undergoing open arthroplasty more at risk. Neuropathy symptoms were refractory to conservative management despite the type of shoulder surgery, type of neuropathy, or EMG severity. Decompression consistently led to resolution of symptoms.

I engage in physical activity while operating a wheelchair.: a systematic review of stroke patients

Introduction: Stroke is a major contributor to mortality rates in numerous nations, resulting in enduring challenges for individuals who have survived the condition in doing routine tasks. The chair-stand exercise was implemented as a distinct intervention, clearly differentiated from a convalescent rehabilitation program. The objective of this study is to gather empirical data on the movement of stroke patients in wheelchairs used by healthcare professionals, given the current lack of clarity in clinical practices. Method: Studies were obtained from PubMed, Embase, Cochrane Library, EBSCO, Web of Science, and CNKI. Only randomized controlled trials were left to evaluate exercises suitable for wheelchair-using stroke patients, and with no restrictions on data or study language. Result: Specifically, six studies utilized interventions such as Trunk Stability, Sit And Stand Independently, Sitting Posture and Trunk Control, Monkey Chair And Band System, Beach Chair Position, and Chair-Stand Exercise. Conclusion: The study's positive outcomes illustrate that engaging in wheelchair exercise can have a beneficial effect and improve the capacities of individuals who have experienced a stroke. Wheelchair users employ many strategies to improve their functioning abilities. Keyword: Sitting Position, Stroke, Wheelchairs, Delivery of Health Care

Arthroscopic Decompression of Calcific Tendinitis of the Shoulder and Repair of Residual Rotator Cuff Defect

Background: Calcific tendinitis is a common source of shoulder pain and represents pathologic deposition of calcium hydroxyapatite within rotator cuff tendon tissue, most commonly the supraspinatus tendon. Indications: Arthroscopic decompression of calcific tendinitis with possible rotator cuff repair is indicated in patients with persistent, debilitating symptoms of pain and/or dysfunction who are recalcitrant to nonoperative treatments, including corticosteroid administration, ultrasound-guided needle barbotage, and/or extracorporeal shockwave therapy. Technique Description: With the patient in a beach chair position, a standard diagnostic shoulder arthroscopy is performed to evaluate for concomitant pathologies. Within the subacromial space, a thorough bursectomy is performed and the area of calcium deposition is localized with a spinal needle. A scalpel may be used to create a small incision through the rotator cuff tendon in line with its fibers to promote egress of calcific debris. Surrounding tissue and loose debris are removed with an arthroscopic shaver. Following decompression, the rotator cuff repair is inspected, and if a bursal-sided or full-thickness tear is identified, an arthroscopic repair is performed with a construct individualized to the specific tear pattern. Results: Surgical treatment conferred greater functional improvement and comparable pain reduction to nonoperative treatments in a systematic review comprised of 27 randomized trials. While the addition of a rotator cuff repair remains controversial, combined excision of calcific tendinitis with concomitant rotator cuff repair led to greater functional outcomes and pain reduction at 2-year minimum follow-up compared with isolated decompression. Conclusion: Calcific tendinitis within the shoulder may be treated successfully with arthroscopic decompression and subsequent repair of a residual rotator cuff defect, followed by a graduated physical rehabilitation program. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Comparison of Hemodynamic Parameters Based on the Administration of Remimazolam or Sevoflurane in Patients under General Anesthesia in the Beach Chair Position: A Single-Blinded Randomized Controlled Trial.

Background: We aimed to evaluate whether the administration of remimazolam as a maintenance agent for general anesthesia affects the occurrence of hypotension compared with sevoflurane when switching to the beach chair position (BCP). Methods: We conducted a prospective randomized controlled trial from June 2023 to October 2023 in adult patients undergoing orthopedic surgery under general anesthesia in the BCP. A total of 78 participants were randomly allocated to the remimazolam (R) or sevoflurane (S) groups. The primary outcome was the incidence of hypotension that occurred immediately after switching to a BCP. The secondary outcomes included differences between the study groups in perioperative blood pressure (BP), heart rate (HR), endotracheal tube extubation time, postoperative complications, and hospital length of stay (LOS). Results: The incidence of hypotension immediately after switching to a BCP was significantly higher in the S group. The risk factors associated with hypotension included sevoflurane administration and a high baseline systolic BP. In the receiver operating characteristic curve analysis for the occurrence of hypotension after the transition to a BCP, the cutoff value for systolic BP was 142 mmHg. The perioperative BP and HR were higher in the R group at several timepoints. Postoperative endotracheal tube extubation time was shorter in the R group. There were no significant differences in the postoperative complications or hospital LOS between the two groups. Conclusions: Remimazolam should be considered as an anesthetic agent to prevent hypotension when switching to BCP, and hypotension may occur frequently in patients with high baseline BP.

Systemic and cerebral hemodynamic changes in patients undergoing shoulder arthroscopy in the beach chair position

Поєднання таких факторів як загальна анестезія та зміна положення тіла після індукції мають вплив на системну та церебральну гемодинаміку. Мета. Bиявити вплив зміни положення тіла та загальної анестезії на пікову систолічну швидкість внутрішньої сонної артерії (ПСШВСА) у пацієнтів під час проведення артроскопії. Методи. 85 пацієнтів із фізичним статусом за ASA I–II, середнього віку (33,0 ± 11,3) років, проведено артроскопію плечового суглоба під загальним наркозом. Основними вимірюваннями були систолічний артеріальний тиск (САТ), діастолічний артеріальний тиск (ДАТ), середній артеріальний тиск та ПСШВСА. Основні вимірювання: в положенні лежачи на столі перед індукцією, через 3 хв після введення в наркоз в положенні лежачи та в положенні пляжного крісла (ППК). Індукцію та забезпечення загальною анестезію проводили сибазоном, пропофолом і фентанілом. Дані проаналізовано статистично. Методи описової статистики використовували для розрахунку середнього, стандартного відхилення, мінімального і максимального значень вибірки. Порівняння проводили за допомогою Т-тесту для повторних порівнянь з розрахунком різниці середніх зі стандартним відхиленням (M ± SD), критичного значення критерію (t) та його статистичної значущості (p). Для порівняння динаміки зміни параметрів було проведено загальний лінійний аналіз з визначенням значення критерію Піллаї та його значення. Аналіз проводився в пакеті IBM SPSS Statistics 20.0. Результати. Початкові дані САТ, ДАТ та середнього артеріального тиску достовірно знижувались після індукції та після позиціонування, але індукція не вплинула на показник ПСШВСА. Після позиціювання до ППК було констатовано значне зниження показників ПСШВСА. Висновки. Констатовано достовірне зниження САТ, ДАТ, середнього артеріального тиску після индукції та подальшого позиціювання хворих у ППК. Постіндукційна гіпотензія не впливає на динаміку ПСШВСА, але виявлено достовірне її зниження після позиціювання.

High accuracy of intra-articular needle position during anterior landmark guided glenohumeral injections

ObjectivesImage-guided ultrasound or fluoroscopic glenohumeral injections have high accuracy rates but require training, equipment, cost, and radiation exposure (fluoroscopy). In contrast, landmark-guided glenohumeral injections do not require additional subspecialist referrals or equipment. An optimal technique would be safe and accurate and have few barriers to implementation. The purpose of this study was to define the accuracy of glenohumeral needle placement via an anterior landmark-guided approach as assessed by direct arthroscopic visualization. MethodsA consecutive series of adult patients undergoing shoulder arthroscopy in the beach chair position were included in this study. Demographic and procedural data were collected. The time required to perform the injection, the precise location of the needle tip, and factors that affected the accuracy of the injection were also assessed. ResultsA standardized anterior landmark-guided glenohumeral joint injection was performed in the operating room prior to surgery, and the location of the needle tip was documented by arthroscopic visualization with a low complication profile and few barriers to implementation. A total of 81 patients were enrolled. Successful intra-articular glenohumeral needle placement by sports medicine and shoulder/elbow fellowship-trained orthopedic surgeons was confirmed in 93.8% (76/81) of patients. The average time to complete the procedure was 24.8 ​s. There were no patient-related variables associated with nonintra-articular injections in the cohort. ConclusionsThis study demonstrated that the technique of anterior landmark-guided glenohumeral injection has an accuracy of 93.8% and requires less than 30 ​s to perform. This method is safe, yields similar accuracy to image-guided procedures, has improved cost and time efficiency, and requires less radiation exposure. No patient-related factors were associated with inaccurate needle placement. Anterior landmark-guided glenohumeral injections may be utilized with confidence by providers in the clinical setting. Level of EvidenceLevel 5.IRB: Approved under Stanford IRB-56323.

Stealing-like phenomenon with interscalene nerve block and its influence on the regional blood flow during shoulder arthroscopic surgery

Background Hypotensive anesthesia during shoulder arthroscopy is mandatory. Hypotension in the supine or decubitus position is safe and effective for reducing blood losses and for maintaining a clear surgical field. However, in the beach chair position, major complications have been reported. The current study claims that the alignment of the vessel in these regions favor a stealing-like phenomenon associated with interscalene block. This phenomenon has a good impact on the surgical field. Results There was a significant change in the peak systolic velocity between the two populations with values of 57±5 in group I versus 90±12 in group G, with a clearer surgical field in group I than in group G. The need for the intraoperative adjuvant analgesics was higher in group G (29 patients) compared with group I (10 patients) as was the pain score at early postoperative intervals of 6 and 12 h. Conclusion The distribution of blood vessels in this region favors a stealing-like phenomenon may be because of the associated vasoplegic effect with the interscalene nerve block, yielding a favorable surgical field without deliberate hypotension.

Iatrogenic Tracheal Rupture after Endotracheal Intubation: A Case Report

Iatrogenic tracheal rupture is very rare condition and has a lot off causes (intubation, tracheostomy, bronchoscopy, esophagectomy), but orotracheal intubation is the most common. Diagnosis is based on the occurrence of symptoms that are not specific but highly suggestive: subcutaneous emphysema, respiratory insufficiency, pneumothorax, and hemoptysis. The appearance of subcutaneous emphysema as a first sign plays a main role for early diagnosis and rapid appropriate treatment. Diagnostic confirmation is possible by chest X-ray, thoracic computed tomography and bronchoscopy which confirmed the size and site of the lesion. Treatment can be conservative, in patients with small ruptures, less than 2 cm, and surgical in the majority of ruptures over 2 cm in length.&#x0D; Our case report presents an iatrogenic post-intubation tracheal rupture treated conservatively. Our patient was a 71-year-old woman, admitted in our hospital with fracture of right humerus for elective surgery. Her medical history was only arterial hypertension. She underwent general anesthesia, intubated with flexible ET tube, positioned in beach-chair position after introduction, and no complication occurred during surgery. 18 hours after surgery, after severe coughing, she suddenly developed subcutaneous emphysema of the facial, neck and upper anterior chest. Tracheal rupture was confirmed with a thoracic computed tomography and tracheobronchial fiber endoscopy. It showed a posterior tracheal transmural rupture 1 cm long, located 4 cm above the carina, covered with small tissue that opened in inspirium. Conservative treatment with antibiotic cover was performed, and the patient was discharged home in good condition, fourteen days after the initial injury.

Arthroscopic-Assisted Core Decompression of Humeral Head Osteonecrosis With Bone Marrow Aspirate Concentrate Augmentation

Background: The proximal humerus is the second-most common anatomic site for osteonecrosis, a condition of disrupted blood supply leading to death of bone tissue, with resultant shoulder pain and dysfunction. Core decompression is a viable joint-preserving surgical intervention that aims to improve local blood supply and restore bone health prior to bony collapse. Indications: Humeral head osteonecrosis has numerous underlying causes, most commonly the sequelae of prior trauma, chronic use of systemic corticosteroids, sickle cell disease, and alcohol abuse. Core decompression may be indicated in the early, pre-collapse stages of osteonecrosis, whereas more advanced stages of disease are commonly indicated for joint reconstruction procedures, such as bone grafting or arthroplasty. Technique Description: With the patient in the beach chair position, bone marrow aspirate concentrate (BMAC) is harvested through a percutaneous incision along the anterolateral proximal humerus. While viewing through a standard posterior portal, a transtibial anterior cruciate ligament (ACL) guide is placed through an anterior portal at a site on the humeral head surface, centered at the area of greatest humeral head bone edema as identified on preoperative magnetic resonance imaging. A guide pin is placed through a lateral portal within the ACL guide, to the subchondral bone. A 7.0-mm reamer is applied over the guidewire, followed by administration of demineralized bone matrix soaked in BMAC into the reamed channel within the proximal humerus. Results: In patients with early stages of humeral head osteonecrosis, core decompression confers superior clinical outcomes with reduced rates of subsequent surgical procedures compared with nonoperative treatment. Core decompression has shown to reduce the radiographic progression of osteonecrosis. Further research is necessary to determine the additional clinical benefits of augmentation with orthobiologic agents, such as BMAC. Conclusion: Arthroscopic-assisted core decompression is a valuable, minimally invasive surgical treatment for early-stage proximal humerus osteonecrosis. Adjunctive treatment with BMAC and demineralized bone matrix may enhance clinical outcomes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic Subdeltoid Humeroplasty in the Beach-Chair Position for Reverse Hill-Sachs Lesions

Reverse Hill-Sachs lesions (HSLs) often involve a greater percentage of the humeral head articular surface than posterior HSLs and frequently require surgical treatment in the setting of posterior shoulder instability. Multiple techniques have been described to treat these lesions depending on their size, acuity, and location. The (modified) McLaughlin procedure is widely used to treat smaller engaging lesions, whereas larger lesions involving a greater percentage of the humeral head articular surface require anatomic disimpaction, termed “humeroplasty.” Humeroplasty is traditionally performed via an open approach. This technical note describes an arthroscopic subdeltoid humeroplasty technique for the reduction and fixation of reverse HSLs in the beach-chair position.

Intramedullary Nailing Technique for Proximal Humeral Fractures Using a Straight Antegrade Nail with Locking Tuberosity Fixation.

Intramedullary straight nail fixation of proximal humeral fractures using a locking mechanism provides advantages compared with plating, including (1) less soft-tissue dissection, which preserves periosteal blood supply and soft-tissue attachments; (2) improved construct stability for comminuted fractures or osteopenic bone; and (3) shorter operative time for simpler fractures. The patient is placed in the beach-chair position with the head of the bed elevated approximately 45°. The fracture is reduced with use of closed or percutaneous methods, ideally, or with an open approach if required. Temporary fragment fixation with percutaneous Kirschner wires can be utilized. A 1-cm incision is made just anterior to the acromioclavicular joint, overlying the zenith of the humeral head and in line with the diaphysis. A guide-pin is then placed through this incision and is verified to be centrally located and in line with the humeral diaphysis on fluoroscopic views. The guide-pin is advanced into the diaphysis. A cannulated 9-mm reamer is inserted over the guide-pin to create a starting position. The nail is then inserted, with adequate fragment reduction maintained until the proximal nail portion is buried under the subchondral humeral head. The proximal screw trajectory and alignment are checked fluoroscopically. The proximal locking screws are pre-drilled and inserted first using percutaneous drill sleeves through the radiolucent targeting jig. The screw is inserted through the guide and is advanced into the nail until appropriately seated. This process is then repeated for the other proximal screws as necessary. Finally, the distal diaphyseal screws are pre-drilled and inserted in a similar percutaneous fashion using the jig, and the jig is removed. Final orthogonal images are obtained. Copious irrigation of the incisions is performed and they are closed and dressed with a sterile dressing. The operative arm is placed in an abduction sling. Alternative treatment options for proximal humeral fractures include nonoperative treatment with use of a sling, percutaneous reduction and internal fixation with Kirschner wires, open reduction and internal fixation with a locking plate and screw construct, hemiarthroplasty, and anatomic or reverse total shoulder arthroplasty1. The presently described technique for proximal humeral fracture fixation using a straight, antegrade, locking nail allows for minimal soft-tissue disruption, preserving vascularity and soft-tissue support and achieving angularly stable fixation in often osteopenic bone. The superior and in-line entry point avoids complications of rotator cuff injury and/or subacromial impingement. The proximal locking screws avoid complications of screw penetration or migration. This technique is appropriate for surgically indicated Neer 2-, 3-, and 4-part humeral fractures, including in elderly patients, when the humeral head fragment remains viable1-5. Based on available Level-III and IV evidence using this technique, patients should expect recovered motion and the ability to perform daily activities independently, with a mean active elevation of 132° to 136°1,4,6, external rotation of 37° to 52°1,4,6, and internal rotation to L31. Pain scores improved significantly from preoperatively to postoperatively, with a mean pain score of 1.4 on the visual analogue scale3,4,6. Patient-reported outcomes were good to excellent, with Single Assessment Numerical Evaluation (SANE) scores of 80% to 81%1,6, mean Constant scores from 71 to 811,3,4,6, and high rates of patient satisfaction (97% satisfied or very satisfied)4. Studies also demonstrated good to excellent fracture healing, with no tuberosity migration and low rates of nonunion (0% to 5%)1,6 and humeral head necrosis (0% to 4%)1,4. Revision rates ranged from 10.5% to 16.7%4,6. The starting position of the guide-pin must be central and at the zenith of the humeral head on the anteroposterior Grashey and the scapular Y views, and the guide-pin must be aligned with the diaphysis prior to advancing it.Failure to bluntly dissect the percutaneous incisions risks injury to the axillary nerve.Verify correct version of the nail prior to drilling any screws, to avoid incorrect version and potential loss of functional rotation. ABD = abductionAP = anteroposteriorCT = computed tomographyER = external rotationFF = forward flexion (forward elevation)IR = internal rotationSANE = Single Assessment Numerical EvaluationSSV = Subjective Shoulder ValueVAS = Visual Analogue Scale.

Anchorless Arthroscopic Transosseous Rotator Cuff Repair.

Rotator cuff repair techniques have evolved over time. The original techniques were open procedures, then surgeons adopted arthroscopic repair procedures with anchors and implants. Today, rotator cuff repair has evolved to be performed as an arthroscopic transosseous technique that is again performed without the use of anchors. In this video, the 5 essential steps of arthroscopic transosseous repair will be demonstrated. (1) Position the patient in either the beach chair or lateral decubitus position. (2) Utilize 4-portal arthroscopy, which allows a consistent vantage point while having 3 other portals for instrumentation. (3) Perform just enough bursectomy to expose the rotator cuff. (4) Anatomically reduce the rotator cuff anatomy where possible. (5) Triple-load the transosseous tunnels with high-strength sutures in order to maximize the biomechanical strength of the repair. Alternative surgical techniques include open rotator cuff repair and single and double-row rotator cuff repair using anchors. The goal of any rotator cuff repair is to anatomically restore the rotator cuff. The fundamental principles include a strong initial biomechanical fixation, cuff footprint anatomy restoration, and maximization of biological factors to promote healing of the rotator cuff. Rotator cuff repair was originally performed as an open procedure, which allows for direct visualization of the tear and repair; however, open repair requires some level of deltoid splitting, which can potentially affect postoperative early mobilization. Single-row and double-row cuff repairs can both be performed arthroscopically. Proponents of the double-row procedure prefer that technique for its footprint restoration and stronger biomechanical fixation; however, the double-row procedure can result in overtensioning of the repair and can lead to medial-based rotator cuff failures. Proponents of the single-row procedure prefer that technique for its ease of operation, fewer implants, lower cost, and low repair tension; however, the single-row procedure fixes the tendon at a single point, limiting the repaired footprint, and can be associated with lower fixation strength. The arthroscopic transosseous rotator cuff repair achieves all of the above goals as it provides strong initial fixation and anatomic footprint restoration, which allows maximal patient biology for healing. There are numerous studies that can attest to the success of arthroscopic transosseous repair. Some of the benefits include decreased health-care costs and postoperative pain levels. In a 2016 study of 109 patients undergoing arthroscopic transosseous rotator cuff repair, Flanagin et al. reported a mean American Shoulder and Elbow Surgeons (ASES) score of 95 and a failure rate of 3.7% at mid-term follow-up1. Similarly, in a study comparing transosseous repair to transosseous equivalent repair, Srikumaran et al. reported that patients undergoing transosseous repair had a mean ASES score of 92 and a failure rate of 14%, with no significant differences between treatment groups2. Finally, in a study assessing the results of arthroscopic transosseous rotator cuff repair at >10 years postoperatively, Plachel et al. reported a mean ASES score of 92 and a failure rate of 27%3. Compared with conventional rotator cuff with anchors, the transosseous cuff repair can lead to cut-out of the repair sutures from the bone.Use a 4-portal arthroscopy technique, which will help the surgeon visualize all tear configurations while instrumenting them.Perform just enough bursectomy, in order to preserve the growth factors for cuff healing.Take care to minimize tuberosity trauma as a result of burring.Prepare the transosseous tunnels with a wide bone bridge.Load each tunnel with 3 high-strength sutures in order to maximize repair strength.Restore the rotator cuff footprint to facilitate tissue healing. ASES = American Shoulder and Elbow SurgeonsRCR = rotator cuff repairATRCR = arthroscopic transosseous rotator cuff repairARCR = arthroscopic rotator cuff repairPDS = polydioxanone sutureROM = range of motionSSV = Subjective Shoulder ValueFF = forward flexionOR = operating roomFU = follow-up.