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.

Placing a lateral leg holder against the outside of the patient's leg holds the knee in place and gives surgeons better access to the inside of the joint. Make sure the holder's post is properly positioned. If it's placed too close to the hip, for example, it won't be as effective as a counter force, meaning the surgeon won't have enough leverage to open up the tight medial aspect of the joint.

Almost all arthroscopic knee procedures are done anteriorly, says Dr. Lubowitz. "We can now use advanced arthroscopic techniques to work in the posterior aspect of the knee from the front of the joint."

For example, you can arthroscopically remove a popliteal cyst in the back of the knee with the patient in the supine position. That's a significant convenience because the removal can be added to other knee procedures without having to reposition the patient.

Dr. Lubowitz says surgeons must place a posterior medial port to remove the popliteal cyst and points out that the procedure requires specific positioning. First, the patient's non-operative leg must be placed in a holder and moved away from the operative site, so the surgeon has enough room to maneuver the 12-inch long shaver needed to perform the procedure. Surgeons approach the joint perpendicular, but also need 6 to 8 inches of clearance in order to direct the shaver posteriorly and anteriorly, and up and down inside the joint.

During knee replacements, the patient is supine and the operative leg is draped with a long stockinette dressing. The surgeon needs to manipulate the leg to ensure implants are placed properly, so the leg has to be movable outside of the drapes. With the leg free, the surgeon can bend and extend it to make sure the implant is positioned correctly.

"The challenge to positioning knee replacement patients is that at times surgeons need to flex the joint," says Ms. Rose. She cautions that proper patient position is even more critical during robotic knee replacements, which are growing in popularity. "If the surgeon's cuts stray outside of the preprogrammed surgical pathway, the saw on the robotic arm will shut down," she explains. "The surgery is very precise."

That precision places added importance on positioning the patient's knee for surgery. Ms. Rose says her surgeons opted to forgo the proprietary boot attachment that came with the robotic system because it was too bulky. They instead opted for placing a padded brace against the patient's thigh to stabilize the joint during surgery and maintain the leg's range of motion. "We came up with something a little simpler and more effective," says Ms. Rose.

Help for hips

Surgeons must be able to see into a joint that is traditionally compacted. "You need to have access to the joint's various compartments, and you need to use traction when working inside the joint," says Dr. Lubowitz. "But too much traction can lead to nerve injury, so you want to be able to adjust the traction when working on the compartments of the hip that are outside the central joint."

The posterior approach to replace hips involves cutting some muscles and tendons, which are re-paired at the conclusion of the procedure and heal afterward. "Although complications are rare following this approach, cutting of the muscles and tendons can weaken the joint area and 1 to 2% of patients suffer posterior dislocation," says Dr. Lubowitz. "There's been a recent movement toward use of anterior approach, which lowers the risk of dislocation quite a bit."

When a patient is supine on a fracture table for the anterior approach, make sure the lateralized perineal post is well padded to minimize risk of pudendal nerve compression. Also ensure the feet are in padded boot holders. The hip distractor system that attaches to the foot of the table must ease the surgeon's entry into the joint and im-prove visualization of the central compartment.

Total team effort

Always focus on protecting the areas of a patient's skin that come in contact with positioners and table attachments. During longer surgeries such as joint replacements, patients are also at risk of developing vascular injury, which could involve the compression of a vein and, ultimately, development of a blood clot. "The decision of how to best position the patient must be based on the surgeon establishing what he needs to have full exposure of the joint," says Ms. Rose. "But nurses must also make sure the patient is positioned safely, that they're properly supported and that there is little shearing or friction between their skin and the surface they're on." OSM