FIRST THINGS FIRST Patient positioning sets the tone for the entire procedure.

Patient positioning can make or break orthopedic procedures. Place patients properly and the anatomy of joints will be fully exposed, letting surgeons situate instruments ideally and access the surgical field with less strain. Do it less than optimally and straightforward procedures become unnecessary challenges. It might be time to remind your staff that focusing on proper patient positioning sets surgeons up for orthopedic success.

Critical start
Patient positioning is a critical variable of surgery, but OR teams exhibit various levels of expertise in ensuring patients are placed as surgeons prefer. A good team that's used to doing the same procedures for the same surgeons can position patients appropriately, but surgeons must always check to make sure they're satisfied with the placement of the knee, shoulder or hip before prepping and draping.

For example, during an ACL repair, the knee must be positioned to allow for the application of varus and valgus forces to provide surgeons with access to the lateral meniscus and medial meniscus, and to obtain enough flexion to place the drill at the correct angle to make the tunnel for the ACL. It's important to gain a balance between the two. If the force or flexion is off even slightly, a circulating nurse might have to go under the drapes to reposition the patient during the procedure, or the surgeon might have to change his preferred technique to get the optimal angles for placing the tunnel.

Positioning obese patients is a definite challenge. They have more soft tissue, which adds to the difficulty of using positioning aids to optimize joint access through larger tissue envelopes. Positioning patients for shoulder procedures is also inherently difficult. Placing the patient in the beach chair position can provide better access for rotator cuff repairs, while the lateral position allows for better traction and improved access to the inferior portion of the glenoid during labral repairs.

During arthroscopies, rotator cuff and labral repairs, and total shoulder replacements, surgeons must position the arm and scapula properly in order to gain adequate exposure of the humerus and glenoid. They must also ensure that the patient's head is positioned in a way that will avoid the anticipated trajectory of instruments, and that the drape is placed far enough away from the surgical site as to not interfere with the placement of drill holes and screws.

User-friendly aids
Protecting patients from unintended harm is one of the most important aspects of proper positioning. Although nerve damage or pressure injuries caused by improper placement on the OR table is a relatively rare occurrence, it's also a complication that positioning devices can help avoid.

The proper use of positioning devices and positioning aids that protect bony prominences or pressure points helps to mitigate the risk of patient harm. But the entire surgical team — the buck stops with the surgeon and anesthesia provider — must constantly monitor the patient to ensure pressure points remain free of the excessive forces that can lead to skin injuries or nerve damage.

When assessing your positioning device options, make sure they're easy for staff to set up, so they can flip rooms between right and left configurations or knee and shoulder procedures without wasting valuable minutes. In addition, surgeons should be able to make small mid-procedure adjustments needed to gain optimal access to the joint. Devices that let surgeons make adjustments as needed without relying on a staff member — for example, articulating shoulder systems that allow slight adjustments to the arm position with the movement of a strap, push of a button or step on a pedal — give surgeons the control they need and free up assistants to focus on clinical matters that are more pressing than holding the knee flexed or arm in place. It might also reduce the number of staff needed in the OR.

Surgeons also want to easily and quickly reproduce effective patient positions. Some ill-designed shoulder systems are restrictive in the way they allow the arm to move, which can add an unnecessary level of difficulty to already challenging joint procedures.

Also look for devices that operate as a complete system. Using options from different manufacturers to position the patient and set arm traction might work, but I've found that solutions designed to operate together work best.

POSITIONING PEARLS
Optimizing Access During Knee Arthroscopy

A LEG UP Proper positioning of the knee lets staff and surgeons apply the forces needed to open up access to the joint.

A report I co-authored in the journal Arthroscopy Techniques (osmag.net/uQ5DXp) reviews the basic principles of positioning a knee arthroscopy patient. The key to positioning for knee arthroscopy is allowing for the application of varus and valgus forces, which open up access to the knee's medial and lateral compartments.

First, place the prone patient's heels at the end of the table to improve the surgeon's access to the knee. Then make sure the pelvis is lined up with the edge of the table to ensure the leg can be leveraged firmly against the leg positioning device or table's post. The surgical team then has 2 main options for positioning the knee:

• Place a circumferential leg holder around the patient's upper thigh and lower the foot off the table to allow for the application of direct varus and valgus forces. A surgical assistant can push the leg laterally to expose the medial compartment or medially to expose the lateral compartment.
• Place a lateral post roughly 5 cm superior to the proximal patella to allow the surgeon or assistant to stand between the bed and the patient's ankle. Then press the patient's thigh against the post to apply valgus force, which improves access to the medial compartment. The knee is placed in the "figure of 4" position for access to the lateral compartment. If access to the intercondylar notch is needed, abduct the hip, bring the patient's knee off the side of the table and lower the post.

— Benjamin D. Ward, MD

Fast learners
No matter how user-friendly the positioner you choose, understand that staff and surgeons need to spend time learning how a device works and master the nuances in setting it up and making small adjustments on the fly.

Surgeons, who each have their own positioning preferences, need to show the OR team how they like patients placed for each procedure. They should understand how positioning devices work and communicate very specific instructions to the staff. Surgeons can walk through specific set-ups for various procedures, observe staff's initial positioning attempts and let them set up on their own before confirming the correct placement. It's ultimately the surgeon's responsibility to verify the position and safety of the patient.

Surgeons and staff must spend time learning how to get the most out of positioning devices and to ensure they're deploying them safely. Once they become familiar with how a device operates and learn its capabilities and limitations, they can focus on improving set-up efficiency. Until then, you can expect cases involving positioning aids to last a few minutes longer, but it'll be time well spent.