Patient In Beach-chair Position Research Articles

Humeral Head Osteochondral Allograft Reconstruction for Chronic Locked Posterior Glenohumeral Dislocation With Large Reverse Hill–Sachs Defect

Background: Locked posterior glenohumeral dislocations are a rare but often missed injury when it occurs. In these dislocations, patients may have a reverse Hill–Sachs lesion, which are associated with high rates of recurrent posterior glenohumeral instability. Open reduction with allograft reconstruction to reconstruct the defect can be used to treat chronic locked posterior glenohumeral dislocations. Indications: Osteochondral allograft reconstruction is indicated when patients have a large defect affecting less than 50% of the articular surface and if the humeral head has been dislocated for less than 6 months. Technique Description: With the patient in beach chair position, exposure is obtained through deltopectoral approach. An open reduction is performed, and the defect is debrided down to healthy bleeding bone. The defect is templated, and the allograft is harvested and prepared. The allograft is securely fixed using cannulated cancellous screws. The patient undergoes a postoperative rehabilitation protocol. Results: There have been several case series following allograft reconstruction for locked posterior dislocations that have demonstrated good results. Riff et al found favorable results in his series of 20 patients with isolated humeral head lesions, with significant improvement in patient-outcome measures. There are several potential complications though. A systematic review by Saltzman et al found allograft resorption to occur in 36% and glenohumeral arthritic changes to occur in 35% with frozen allografts. These rates appear to be improved with fresh allografts. Discussion/Conclusion: In conclusion, osteochondral allograft is an effective surgical treatment for large Hill–Sachs defects in chronic locked posterior dislocations.

Rotator cuff irreparability or failure of repair (re-tear): technical note on middle trapezius tendon transfer for reproduction of supraspinatus function

PurposeBased on its close anatomic features and nearly-collinear force vector to those of supraspinatus muscle, the current article describes a technique of middle trapezius tendon transfer for reproduction of supraspinatus function in the context of rotator cuff irreparability/re-tear management.MethodsWhile seating the patient in beach-chair position, arthroscopic gleno-humeral examination and sub-acromial decompression are initially performed. Hamstring tendons are harvested and fashioned as flattened quadruple sheet. Through McKenzie approach, infraspinatus and subscapularis tendons are repaired. Then, medial half of middle trapezius insertion tendon is harvested from most medial 5-6 cm of the scapular spine. Through McKenzie approach, hamstring sheet is retrieved via a sub-trapezius/sub-acromial corridor from the scapular wound. Hamstring sheet is re-attached to cuff footprint by double row/suture bridge repair configuration. While retracting the scapula and placing gleno-humeral joint in 45O-abduction/45O-external rotation, hamstring sheet is re-attached to released middle trapezius tendon by non-absorbable sutures. Finally, tendon reconstruct is dynamically-tested in different positions of range of motion.ResultsTransfer of medial portion of middle trapezius insertion tendon (lengthened by interposition hamstring tendon sheet) to cuff footprint was technically feasible. Dynamic testing showed smooth sub-acromial gliding motion of the tendon reconstruct.ConclusionFor reproduction of supraspinatus function, hamstring tendon augmented-middle trapezius tendon transfer to cuff footprint heralds a number of technical and biomechanical advantages; thus offering a potential effective modality of cuff irreparability/re-tear management in relatively young patients of high functional demands. However, current description should be investigated in further biomechanical and clinical studies to validate its long-term outcomes.

Arthroscopic Distal Clavicle Resection Through the Supraspinatus Fossa Portal

Disorders of the acromioclavicular (AC) joint quite often necessitate distal clavicle resection (DCR). Arthroscopic DCR is favored because of it is mini-invasive and convenient to treat concomitant intraarticular or subacromial lesions. In previous reports, arthroscopic DCR was performed through the anterior portal with the patient in beach chair position. However, when the patient is in the lateral decubitus position, it is inconvenient to perform DCR through the anterior portal. Thus, we introduce a special DCR technique through the supraspinatus fossa (SSF) portal. The critical point of this technique is viewing the acromioclavicular joint through the routine posterior portal, creating the SSF portal at the anterior edge of the scapular spine and the same medial-to-lateral level to the AC joint, and enough removal of the posterior edge of the distal clavicle. We believe the introduction of this technique will provide a special technical option when DCR is needed.

Randomized Trial of the Use of Dexmedetomidine vs. Propofol after Regional Blockade in Shoulder Surgery Patients in Beach Chair Position

Background: Propofol is often the drug of choice for ambulatory orthopedic cases. However, propofol can be associated with apnea or other events requiring airway interventions. Dexmedetomidine (Dex) has the unique pharmacologic profile of providing sedation without respiratory depression. This is particularly relevant in patients with morbid obesity and/or challenging airways. The hypotheses were: 1) Propofol would cause more apnea or require more airway manipulations than dexmedetomidine; 2) Propofol would have shorter post anesthesia unit recovery times; and 3) Dexmedetomidine would be associated with more bradycardia and hypotension. Methods: After IRB approval, 50 patients were randomized to receive either propofol or Dex for Total Intravenous anesthesia (TIVA) after interscalene brachial plexus block was performed preoperatively under ultrasound guidance. The main end points that we measured where: airway interventions, intra-operative bradycardia, hypotension, and PACU length of stay. Results: There were more airway interventions in the propofol group compared to the Dex group. Additionally, the Dex group had significantly longer PACU stays. Conclusion: We would recommend that Dex should be preferentially considered for patients predisposed to airway obstruction; however, the standard use of Dex over Propofol needed to reconsider since the use of Dex as the agent for TIVA was associated with longer PACU stays.

Shoulder arthroscopy and complications: Can we afford to relax?

Shoulder arthroscopy and complications: Can we afford to relax?

Acromion reconstruction after arthroscopic subacromial decompression and iatrogenic acromial destruction

Reconstruction of the acromion, to achieve pain relief and better function of the deltoid muscle. After partial or complete removal of the acromion. General surgical contraindications. Paresis of the axillary nerve. Strategy of the operation with X-ray and CT scan. Patient in beach chair position. Disinfection of the shoulder and lateral pelvic region. Exploration of the defect area and searching for the lateral clavicula and spinascapulae end. Removal of a pelvic bone block. Fixation of the pelvic bone block to the spina scapulae with K-wires and finally osteosynthesis by a Reco plate (Synthes, Umkirch, Germany), wound closure. For the first 6 weeks, a cast with the arm in 90° abduction. Passive motion without the cast should be performed once a day. Starting in week 7, weekly reduction of abduction (90°/60°/30°/0°). Active mobilization starting in week 10. Start to practice with weight bearing in week 13. Pain relief improved from VAS 7-9 to VAS 2-3. Improved ROM can be seen postoperatively and after 6 months for abduction/adduction 50-0-50°, anteversion/retroversion 80-0-10°, rotation out/in 40-0-10°.

The influence of basic ventilation strategies and anesthetic techniques on cerebral oxygenation in the beach chair position: study protocol

BackgroundBeach chair positioning during general anesthesia is associated with a high incidence of cerebral desaturation; poor neurological outcome is a growing concern. There are no published data pertaining to changes in cerebral oxygenation seen with increases in the inspired oxygen fraction or end-tidal carbon dioxide in patients anesthetized in the beach chair position. Furthermore, the effect anesthetic agents have has not been thoroughly investigated in this context. We plan to test the hypothesis that changes in inspired oxygen fraction or end-tidal carbon dioxide correlate to a significant change in regional cerebral oxygenation in anesthetized patients in beach chair position. We will also compare the effects that inhaled and intravenous anesthetics have on this process.Methods/designThis is a prospective within-group study of patients undergoing shoulder arthroscopy in the beach chair position which incorporates a randomized comparison between two anesthetics, approved by the Institutional Review Board of the University of Michigan, Ann Arbor. The primary outcome measure is the change in regional cerebral oxygenation due to sequential changes in oxygenation and ventilation. A sample size of 48 will have greater than 80% power to detect an absolute 4-5% difference in regional cerebral oxygenation caused by changes in ventilation strategy. The secondary outcome is the effect of anesthetic choice on cerebral desaturation in the beach chair position or response to changes in ventilation strategy. Fifty-four patients will be recruited, allowing for drop out, targeting 24 patients in each group randomized to an anesthetic. Regional cerebral oxygenation will be measured using the INVOS 5100C monitor (Covidien, Boulder, CO). Following induction of anesthesia, intubation and positioning, inspired oxygen fraction and minute ventilation will be sequentially adjusted. At each set point, regional cerebral oxygenation will be recorded and venous blood gas analysis performed. The overall statistical analysis will use a repeated measures analysis of variance with Tukey’s HSD procedure for post hoc contrasts.DiscussionIf simple maneuvers of ventilation or anesthetic technique can prevent cerebral hypoxia, patient outcome may be improved. This is the first study to investigate the effects of ventilation strategies on cerebral oxygenation in patients anesthetized in beach chair position.Trial registrationNCT01535274