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Hoffman RA, Green A, Paxton ES. Optimizing Visualization in Shoulder Arthroscopy: An Evidence-Based Guide. J Am Acad Orthop Surg 2024:00124635-990000000-01033. [PMID: 38996206 DOI: 10.5435/jaaos-d-23-01025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Indexed: 07/14/2024] Open
Abstract
Advances in arthroscopy have contributed toward improved understanding and management of diverse pathological conditions in the shoulder. As a result, arthroscopy is often preferred by both patients and surgeons. However, surgery can be complicated by limited visualization. Techniques to improve visualization include patient and portal positioning, mechanical débridement, radiofrequency ablation, epinephrine added to irrigation fluid, tranexamic acid administration, and controlled hypotensive anesthesia. Despite published literature on each, a thorough understanding of the evidence supporting these techniques and adjuvants is essential to interpret the clinical utility of each.
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Affiliation(s)
- Ryan A Hoffman
- From the Division of Shoulder and Elbow Surgery, Warren Alpert Medical School of Brown University, Providence, RI
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Lee S, Seo J, Kim DY, Lee Y, Kang HY, Choi JH, Kim Y, Kim MK, You AH. 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. J Clin Med 2024; 13:2364. [PMID: 38673637 PMCID: PMC11051199 DOI: 10.3390/jcm13082364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/16/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ann Hee You
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul 02447, Republic of Korea; (S.L.); (J.S.); (D.Y.K.); (Y.L.); (H.Y.K.); (J.-H.C.); (Y.K.); (M.K.K.)
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Groene P, Schaller T, Zeuzem-Lampert C, Rudy M, Ockert B, Siebenbürger G, Saller T, Conzen P, Hofmann-Kiefer K. Postoperative cognitive dysfunction after beach chair positioning compared to supine position in orthopaedic surgery in the elderly. Arch Orthop Trauma Surg 2024; 144:575-581. [PMID: 37889318 DOI: 10.1007/s00402-023-05109-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/12/2023] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Postoperative cognitive dysfunction (POCD) occurs in up to 26% of patients older than 60 years 1 week after non-cardiac surgery. Intraoperative beach chair positioning (BCP) is advantageous for some types of shoulder surgery. However, this kind of positioning leads to a downward bound redistribution of blood volume, with possible hypoperfusion of the brain. We hypothesized that patients > 60 years undergoing orthopaedic shoulder surgery in a BCP might experience more POCD than patients operated in the supine position (SP). MATERIAL AND METHODS A single-centre, prospective observational trial of 114 orthopaedic patients was performed. Study groups were established according to the type of intraoperative positioning. Anaesthesiological management was carried out similarly in both groups, including types of anaesthetics and blood pressure levels. POCD was evaluated using the Trail Making Test, the Letter-Number Span and the Regensburger Word Fluency Test. The frequency of POCD 1 week after surgery was considered primary outcome. RESULTS Baseline characteristics, including duration of surgery, were comparable in both groups. POCD after 1 week occurred in 10.5% of SP patients and in 21.1% of BCP patients (p = 0.123; hazard ratio 2.0 (CI 95% 0.794-5.038)). After 4 weeks, the incidence of POCD decreased (SP: 8.8% vs. BCP: 5.3%; p = 0.463). 12/18 patients with POCD showed changes in their Word Fluency Tests. Near-infrared spectroscopy (NIRS) values were not lower in patients with POCD compared to those without POCD (54% (50/61) vs. 57% (51/61); p = 0.671). CONCLUSION POCD at 1 week after surgery tended to occur more often in patients operated in beach chair position compared to patients in supine position without being statistically significant.
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Affiliation(s)
- Philipp Groene
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Tanja Schaller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Catharina Zeuzem-Lampert
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Margret Rudy
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ben Ockert
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Georg Siebenbürger
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Peter Conzen
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Klaus Hofmann-Kiefer
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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Yang YF, Huang JW, Gao XS, Xu ZH. Surgical Position of Lateral-Tilted Supine is Suitable for Proximal Humeral Fracture Operations in Geriatric Patients. Geriatr Orthop Surg Rehabil 2022; 13:21514593221136797. [PMID: 36310892 PMCID: PMC9597008 DOI: 10.1177/21514593221136797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To report a new surgical position of lateral-tilted supine (LTS) for geriatric proximal humeral fracture operations. METHODS Between January 2016 and December 2020, we adopted the LTS position for operations in 65 geriatric patients with proximal humeral fractures. RESULTS Sixty-five patients including 25 males and 40 females aged 80.3 ± 8.5 years. The LTS position could be used for almost all proximal humeral fracture surgeries, such as ORIF with plate, suture anchor, and other fixation in 4 patients, open reduction and internal fixation (ORIF) with multiLoc nailing in 48, and shoulder hemiarthroplasty (SHA) in 13. Surgical position setting times were 11.47 ± 2.14 min. The systolic blood pressure changes before and after positioning were 15.07 ± 8.72 mmHg. All of the C-arm X-ray directions, including the cephalic side, contralateral side, and ipsilateral side, can be used in the LTS position surgeries. No surgical complications or no surgical position-related complications were found in these 65 cases. CONCLUSION The surgical position of LTS is suitable for geriatric proximal humeral fracture operations.
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Affiliation(s)
- Yun-fa Yang
- Department of Orthopaedic Surgery, Guangzhou First People's
Hospital, The Second Affiliated Hospital, School of Medicine, South
China University of Technology, Guangdong, China,Yun-fa Yang, Department of Orthopaedic
Surgery, Guangzhou First People's Hospital, the Second Affiliated Hospital,
School of Medicine, South China University of Technology, 1 Panfu Road,
Guangzhou, 510180, Guangdong, China. ,
| | - Jian-wen Huang
- Department of Orthopaedic Surgery, Guangzhou First People's
Hospital, The Second Affiliated Hospital, School of Medicine, South
China University of Technology, Guangdong, China
| | - Xiao-sheng Gao
- Department of Orthopaedic Surgery, Guangzhou First People's
Hospital, The Second Affiliated Hospital, School of Medicine, South
China University of Technology, Guangdong, China
| | - Zhong-he Xu
- Department of Orthopaedic Surgery, Guangzhou First People's
Hospital, The Second Affiliated Hospital, School of Medicine, South
China University of Technology, Guangdong, China
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Gould HP. CORR Insights®: What Is the Risk of Intraoperative Cerebral Oxygen Desaturation in Patients Undergoing Shoulder Surgery in the Beach Chair Position? Clin Orthop Relat Res 2021; 479:2688-2690. [PMID: 34397471 PMCID: PMC8726561 DOI: 10.1097/corr.0000000000001914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/06/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Heath P Gould
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
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Thanaboriboon C, Vanichvithya P, Jinaworn P. What Is the Risk of Intraoperative Cerebral Oxygen Desaturation in Patients Undergoing Shoulder Surgery in the Beach Chair Position? Clin Orthop Relat Res 2021; 479:2677-2687. [PMID: 34128914 PMCID: PMC8726564 DOI: 10.1097/corr.0000000000001864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/26/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have shown that intraoperative cerebral desaturation in patients undergoing shoulder surgery in the beach chair position varies widely, from 0% to 80%. To our knowledge, the risk of intraoperative cerebral desaturation is not known after all identified intraoperative modifiable physiologic parameters that influence cerebral blood flow have been controlled for. QUESTIONS/PURPOSES (1) What is the risk of intraoperative cerebral desaturation during shoulder surgery with the patient in the beach chair position when patients received combined general anesthesia and an interscalene block, and what other factors associated with intraoperative cerebral desaturation can be identified? (2) Is intraoperative cerebral desaturation associated with 24-hour cognitive decline? (3) What factors are associated with intraoperative hypotension? METHODS Between April and December 2020, 51 patients underwent elective shoulder surgery in the beach chair position at one center. Nine patients were excluded: four patients refused to participate, two patients were unable to receive an interscalene brachial plexus block, and three patients were operated on in less than 70° upright position. A total of 42 patients (aged 63 ± 10 years, of whom 52% [22 of 42] were female) were prospectively recruited into this study. Each patient was diagnosed with a rotator cuff tear and underwent arthroscopic repair in the beach chair position, which was performed in an upright position of 70° to 80°. Near-infrared spectroscopy was used to monitor regional cerebral oxygen saturation. The mean arterial pressure was monitored and controlled so that it was more than 70 mmHg in patients without hypertension and within 20% from the baseline mean arterial pressure in patients with hypertension. All patients received the standardized anesthesia protocol, which consisted of an interscalene brachial plexus block and general anesthesia. Intraoperative cerebral desaturation was defined as a decrease in the regional cerebral oxygen saturation level of more than 20% from the baseline value that lasted longer than 15 seconds after induction of anesthesia. Patients' clinical characteristics such as age, sex, BMI, preoperative hemoglobin level, preexisting medical conditions, and continuing antihypertensive medications on the morning of surgery were analyzed to identify the association with intraoperative cerebral desaturation. We used the Montreal Cognitive Assessment to assess cognitive function at preoperative and 24 hours postoperative. Episodes of hypotension and its treatment after maximum head elevation were recorded. The patients' clinical characteristics were analyzed to determine their association with hypotensive events. RESULTS In this study, intraoperative cerebral desaturation occurred in 43% (18 of 42) of patients, and female sex was identified as an associated risk (odds ratio 4.3 [95% confidence interval 1.2 to 16.2]; p = 0.03). The median (interquartile range) duration of intraoperative cerebral desaturation was 19 minutes (5 to 38). There was no association between intraoperative cerebral desaturation and 24-hour postoperative cognitive decline (OR 0.6 [95% CI 0.1 to 2.4]; p = 0.44). Risk factors for intraoperative hypotension were a history of hypertension, regardless of whether or not the patient took antihypertensive drugs on the morning of surgery (OR 4.9 [95% CI 1.3 to 18.1]; p = 0.02), and dyslipidemia (OR 4.3 [95% CI 1.2 to 16.3]; p = 0.03). CONCLUSION The intraoperative cerebral desaturation risk in the beach chair position was high. Female sex was an intraoperative cerebral desaturation risk factor. However, there was no association between intraoperative cerebral desaturation and postoperative cognitive decline. Patients with hypertension and dyslipidemia are at risk of intraoperative hypotension after positioning. Further large-scale studies are required to identify intraoperative cerebral desaturation-associated adverse neurologic outcome. LEVEL OF EVIDENCE Level II, therapeutic study.
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Affiliation(s)
- Chanon Thanaboriboon
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Panramon Vanichvithya
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pongkwan Jinaworn
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Cutbush K, Italia K, Narasimhan R, Gupta A. Frozen Shoulder 360° Release. Arthrosc Tech 2021; 10:e963-e967. [PMID: 33981537 PMCID: PMC8084753 DOI: 10.1016/j.eats.2020.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/13/2020] [Indexed: 02/03/2023] Open
Abstract
Arthroscopic capsular release has emerged as a safe and reliable method for treating severe frozen shoulder in patients with significant loss of range of motion. This article describes a reproducible technique for arthroscopic 360° release of the shoulder performed in the lateral decubitus position.
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Affiliation(s)
- Kenneth Cutbush
- University of Queensland, Brisbane, Australia,Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, Australia,Address correspondence to Kenneth Cutbush, M.B.B.S., F.R.A.C.S., F.A.Orth.A., Level 4, Front Building, 259 Wickham Terrace, Brisbane QLD 4000, Australia.
| | - Kristine Italia
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, Australia,St. Luke’s Medical Center, Manila, Philippines
| | | | - Ashish Gupta
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, Australia
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Stetson WB, Morgan SA, Polinsky S, Chung B, Hung NJ. Cost Effective Technique of Shoulder Arthroscopy Without the Use of Epinephrine in Irrigation Solution. Arthrosc Tech 2021; 10:e411-e418. [PMID: 33680773 PMCID: PMC7917405 DOI: 10.1016/j.eats.2020.10.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/17/2020] [Indexed: 02/03/2023] Open
Abstract
Arthroscopic surgery of the shoulder joint and the subacromial space requires adequate visualization to be effectively performed. Visual clarity is essential to perform a safe and successful arthroscopic procedure. The major determinants to provide visualization in the subacromial space and the glenohumeral joint include adequate inflow (dependent on the dimension of the inflow cannula), flow rate versus pressure, pump system versus gravity, the use of electrocautery and radiofrequency devices, blood pressure control and hypotensive anesthesia, and the type of irrigation solution used with or without the use of epinephrine. In 2012, the cost of a 30-mL (30-mg) vial of epinephrine was $6 (adrenalin/epinephrine injection, USP, Par Pharmaceuticals), and approximately 3 to 4 bottles would be used on average for a single shoulder arthroscopy. In 2019, the same 30-mL bottle of epinephrine cost $237, a nearly 40-fold increase. The purpose of our study is to describe the various factors and techniques that can be used to maintain visual clarity in shoulder arthroscopy without the use of epinephrine in the irrigation solution and the cost savings associated without the use of epinephrine.
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Affiliation(s)
- William B. Stetson
- Stetson Lee Orthopedics and Sports Medicine, Burbank, California, U.S.A.,Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A.,Address correspondence to William B. Stetson, M.D., Stetson Lee Orthopedics and Sports Medicine, 191 South Buena Vista St., Ste. #470, Burbank, CA 91505.
| | | | - Samuel Polinsky
- Stetson Lee Orthopedics and Sports Medicine, Burbank, California, U.S.A
| | - Brian Chung
- Stetson Lee Orthopedics and Sports Medicine, Burbank, California, U.S.A.,Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Nicole J. Hung
- Stetson Lee Orthopedics and Sports Medicine, Burbank, California, U.S.A
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Editorial Commentary: "A Rush of Blood From the Head"-Predicting and Preventing Cerebral Deoxygenation During Beach-Chair Shoulder Surgery. Arthroscopy 2019; 35:731-733. [PMID: 30827426 DOI: 10.1016/j.arthro.2018.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 11/30/2018] [Indexed: 02/02/2023]
Abstract
Orthopaedic surgeons and anesthesiologists need to work together to avoid catastrophic cerebral ischemic injuries when surgery is performed with patients in the beach-chair position. Patient risk factors include body mass index but are not strongly predictive. Anesthetic management choices, such as regional anesthesia with sedation or normotensive general anesthesia with gradual and limited head elevation and hypercapnia, can significantly decrease the risk of cerebral deoxygenation.
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