Archive Orthopedic Surgery 2018

Position Patients for Surgical Success

Surgeons want easy access and maximum exposure when working in shoulders, hips and knees.

Mike Morsch

Mike Morsch, Associate Editor


A LEG UP Spending a few extra minutes before procedures to ensure patients are positioned properly will help surgeons operate more efficiently.

Orthopedic surgeons appreciate working with high-torque drills and high-speed shavers, but they mostly want to move their instruments in and around joints freely and easily. That requires placing patients just so on the surgical table with their extremities supported and their joints exposed.

"The importance of patient positioning to a surgeon is all about, in a word, access," says James H. Lubowitz, MD, founding director emeritus of the Taos (N.M.) Orthopaedic Institute in New Mexico.

With that in mind, here's how to ensure your surgeons have no trouble getting to where they need to go during joint repairs and replacements.

Seeing the shoulder

To provide shoulder access, patients are placed in the lateral or "beach chair" position for shoulder arthroscopies and replacements. When positioning patients laterally, place positioner pegs at the sternum, pelvis and back to stabilize the patient. Use an axillary nerve protector underneath the armpit to protect the patient's skin.

When placing patients in the beach chair position, ensure the patient is tilted 30 to 40 degrees in the chair to prevent slippage. The non-operative arm can be secured in the patient's lap or in a sling to keep it away from the operative field.

"The beach chair position is good for obese patients because it doesn't constrict ventilation," says Reagan Rose, BA, BSN, RN, CNOR, perioperative nurse educator at Temple University Hospital in Philadelphia, Pa. "But it can also cause a lot of pressure on the coccyx and ischial tuberosities, so make sure patients are properly supported and that their buttocks is padded."

When choosing shoulder positioning devices, look for models that stabilize the joint and provide enough distraction for the surgeon to work on the front, back, side and top of the shoulder, says Dr. Lubowitz. "We want wide access — 270 degrees in 2 different planes," he explains.

Some positioners hold the operative arm in place and let the surgeon apply and adjust traction without assistance. That's a nice feature and frees up nurses in the room to focus on other responsibilities.

Accessing the knee

During knee arthroscopy, when patients are supine, place them as close to the side of the bed as possible so surgeons can distract the knee enough to gain optimal access to the joint's various compartments. Also place a support under patients' legs, so the heels aren't touching the table surface. Also slide a pillow underneath the knees to prevent stretching of the peroneal nerve.

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