Per patient positioning prevents poor performance. “One of my mentors told me that, and I’ll never forget it,” says surgeon Gabe Horneff, MD, a shoulder specialist at the Rothman Orthopaedic Institute in Philadelphia, Pa. The self-described “stickler” for making sure patients are placed just so before surgery has been known to ask the surgical team to start the positioning process over if proper alignment is off by even a hair. It’s that important to him.

“Good access starts at the skin incision,” says Dr. Horneff. “If you don’t have it there, you’re going to regret that you didn’t position patients properly as you go deeper into the joint.”

Your surgeons likely share Dr. Horneff’s passion for positioning, so let’s look at effective ways to give them the joint access they want and need at the hip, knee and shoulder — all the while keeping patients safe.

There’s some debate over whether the anterior or posterior approach is best for total hips, but there’s no doubt patient positioning is critically important for both.

• Posterior. Patients are positioned on their sides in the lateral decubitus position. Pegboards — a flat surface roughly the size of an OR table with dozens of tiny peg holes spread throughout — are simple devices that attach directly to a standard OR table and offer surgeons the ability to position and stabilize a variety of different-sized patients in the lateral position.

After patients are anesthetized, they’re rolled onto their sides and the pegs are strategically placed to ensure stability and proper positioning. For example, anterior pegs are placed near the pubic region and directly below the pectoral muscle. Posterior pegs go near the scapula, as well as in the lumbar and sacral areas. Padding is used to cover the area where the patient lays.

“The leg profile pegs let me move the hip in a variety of different positions during the surgery, so I can make sure it’s still stable inside the socket,” says Mitchell C. Weiser, MD, the fellowship director of adult reconstruction at Montefiore Health System in Bronx, N.Y.

When placing patients in the lateral position, pay close attention to how much stress you place on the sciatic nerve and avoid flexing the hip. The lateral position also compresses the axillary nerve. Placing an axillary roll beneath the patient’s ribs relieves pressure near the nerve, says Dr. Weiser. He also says skin pressure ulcers can occur around the greater trochanter and the head of the fibula, and suggests applying plenty of padding in those areas.

• Anterior. With patients in the supine position, be aware of the pressure that’s applied on both the sciatic and femoral nerves. Positioning patients to give surgeons clear access is particularly critical during this approach, as hip instruments are moving around the femoral artery.

Total knee patients are generally placed in the supine position, their knees flexed at about 90 degrees with a maximum amount of flexibility.

Dr. Bates relies on a lateral post and foot bump positioner to perfect knee positioning. It’s a simple attachment that mounts directly to the OR table and provides stability at the joint and foot padding, which is essential for preventing pressure injuries.

When using this positioning technique, “Avoid putting too much pressure on the perineal nerve at the fibular neck by leaning on it or pushing it against the post,” says Dr. Archdeacon.

There are plenty of other simple positioning devices that can be used for total knees, such as femur and tibia triangles, which fit directly under the knee to form a triangle when the knee is properly bent and the foot is resting on the table.

While the feet are resting firmly on the table during total knee replacements, surgeons often have the leg hanging off the table’s edge during arthroscopic procedures. “Surgeons are always moving and repositioning the leg to look behind corners in the joint,” says Dr. Bates.

Although more leg flexibility is needed during arthroscopies, you still want to keep the thigh stable. There are a number of positioning aids you can attach to a standard OR table to achieve that goal.