1. Module #1 James E. Carpenter, MD Peter M. Murray, MD Sterile Technique & Ortho. Surgery Room Setup Developed by the Surgical Skills Task Force of the American Board of Orthopaedic Surgery (ABOS) in collaboration with the American Academy of Orthopaedic Surgeons (AAOS), and the American Orthopaedic Association (AOA)/Council of Orthopaedic Residency Directors (CORD) Presentation #3: Preparing a Patient’s Shoulder for Surgery

2. Preparing a patient for shoulder surgery ABOS/AAOS Surgical Skills Task Force 2013

3. Before entering the O.R. Identify patient, mark site per AAOS guidelines: – “X” on site with initials – Level written for spine cases – Mark must be visible after prepping and draping Patient communication: – Explain process – Last questions – Identify family/friend contact

4. Pre-op Safety Checklist (AAOS)

5. Shoulder surgery Beach chair position – Most common – Open and arthroscopy Lateral position – Arthroscopy: instability – Unusual cases

6. Positioning considerations Neutral neck position – Varies by patient – Kyphosis common in elderly Protect uninvolved arm – Ulnar nerve free of compression – Neutral wrist position (slightly dorsiflexed) Protect legs – SCD’s – Heels, peroneal nerves free of compression

7. Beach chair position 1 Position on table with trochanters at flex point Flex knees over leg support cushion

8. Beach chair position 2 Place head supports and sit up 50-70 degrees Adjust to achieve neutral neck position for that patient, careful with kyphosis

9. Beach chair position 3 Outline area for prepping with steridrapes or equivalent

10. Beach chair position 4 Suspend arm from IV pole with Kerlix or stockinette Leave long loop so that pole can be moved further from field

11. Beach chair position 5 Prep field – Chloraprep or other chlorhexadine prep preferred – Work from incisional area outward

12. Beach chair position 6 Draping: plan on using two layers of impervious draping over most of area Start with first layer from below, then above

13. Beach chair position 7 Use 2 “U” drapes, first from below, then from above For arthroscopy can use drapes with fluid collection pouches

14. Beach chair position 8 Hold arm with towel, circulator releases kerlix/stockinette Sterile extremity sleeve rolled down over hand to elbow

15. Beach chair position 9 If arm holder is to be used the arm is strapped to forearm holder Coban/tape applied to secure arm – Avoid tight wrap at elbow, risk for nerve injury high!

16. Beach chair position 10 Ioban sheet cut into pieces (e.g. ½, ¼, ¼) Axilla drapped over, impervious stockinette is sealed, edges of drapes secured to skin

17. Lateral position 1 Position on bean bag slightly tipped back, “axillary” roll goes under upper chest (not in axilla) Secure with wide tape to prevent loss of position Neck in neutral position with blankets Down leg protected (peroneal nerve) Pillow between legs

18. Lateral position 2 Outline site with steridrapes (or equivalent) Suspend arm from IV pole, keep loop long

19. Lateral position 3 Use two layers of drapes First layer drapes at edges of field (usually smaller drapes) The 2 “U” drapes, one from below, one from above

20. Lateral position 4 Hold arm with towel, circulator releases kerlix Sterile sleeve is rolled down to elbow Arm is wrapped with Coban with loop at hand No tight wrap at elbow, high risk for nerve injury!

21. Lateral position 5 Ioban cut into pieces (e.g. ½, ¼, ¼) Axillla draped off Stockinette sealed, edges of drape secured

22. Preparing patient for shoulder surgery Positioning, prepping, draping complete! Ready for Surgical TIME OUT