**2. Positioning and draping**

The semirecumbent, or beach-chair position, is the optimum position for open approaches to glenohumeral joint. It allows improved orientation for the surgeon, optimal rotational control of the arm, and allows for gravity traction on both the glenohumeral joint and the subacromial space [8]. It is critical that patient positioning allows for stabilization of the scapula to assure proper glenoid orientation. Additionally, equally important is that the patient is placed in a position on the operating table that allows for extension of the shoulder. Failure to recognize this is one of the most commonly made mistakes that can result in difficulty in exposure for both delivery of the proximal humerus out of the surgical wound and adequate exposure of the glenoid (**Figure 1**).

To begin, the patient should be transferred to the operating table and placed into the supine position for intubation. After successful induction of general anesthesia, the patient should be appropriately positioned on the table while supine in order to allow for the safest and easiest transition to the beach-chair position. While the patient is being elevated into position, the anesthesiologist should maintain cervical support while monitoring the airway. The head support should then be elevated to fit the patient's occiput and secured in place. Care must be taken to ensure that the patient's cervical spine remains in a neutral position as anesthesia literature has shown evidence of cerebrovascular and airway incidents that are felt to be caused by inappropriate cervical positioning and subsequent kinking of the carotid artery or trachea [9, 10]. The head should then be secured to the head support in a secure fashion and the endotracheal

**Figure 1.** Appropriate positioning and preparation of the shoulder. Please note that the operative shoulder is placed off the edge of the table to allow for extension of the shoulder during the procedure.

tube should be positioned toward the nonoperative side. A pre-scrub with chlorhexidine, alcohol, and/or hydrogen peroxide may then be performed. Finally, a sterile skin preparation with chlorhexidine may be applied prior to final draping. The final draping should consist of down sheets to cover the head and lower extremities with split drapes or a specialized shoulder drape may be used to isolate the operative shoulder. The distal extremity can be placed in a stockinette and covered with a coban wrap, if preferred. An iodine-impregnated plastic drape or any other sterile adhesive dressing may be used to ensure that the edges of the drape adhere to the skin, ensuring a sterile field through the duration of the case. Prior to skin incision, it is important to administer appropriate antibiotics. Typically, this involves a second-generation cephalosporin such as cefazolin or, if the patient has an allergy to penicillin, clindamycin may be substituted. If preoperative testing indicates that the patient is colonized with methicillin-resistant *Staphylococcus aureus* (MRSA), studies show an increased risk of surgical-site infection [11]. In these situations, it is recommended either to decolonize the patient before the surgery or to give a one-time dose of vancomycin [12]. In addition to antibiotics, pre-incision intravenous administration of tranexamic acid has been shown in multiple studies to decrease intraoperative blood loss [13, 14]. At this point, skin incision is ready to be made.
