Clinical Tip: Semi-Prone Position for Achilles Tendon Surgery

Achilles tendon surgery is a common procedure in general orthopaedic and sports clinics. Most patients are placed prone for Achilles tendon surgery. We describe an alternative position, which gives good surgical exposure and is relatively simple. It also decreases some of the problems and risks associated with full prone positioning of the patient. Optimal patient positioning for surgery enables ease of access to the operative field, manipulation (where limbs are involved) and less blood loss during surgery. The surgeon’s choice of position has implications for the anesthetist who must maintain an adequate airway, breathing, and circulation for the patient. Positioning, therefore, requires a degree of compromise between the needs of the surgeon and anesthetist. In Achilles tendon surgery the prone position often is adopted (historically) because it offers good surgical access. Prone positioning of patients has a number of anesthetic implications. In this position, the anesthetist has poor access to the airway, particularly in an emergency. Most patients placed prone undergo tracheal intubation with an armored flexible tracheal tube to protect the airway. Other problems specific to prone positioning include pressure on the abdomen, which results in increased intrathoracic pressure and decreased thoracic compliance. This is a problem in obese patients because it can make ventilation difficult and lead to basal atelectasis. There also is a high risk of monitoring lines being dislodged. Peripheral pressure areas are at risk with prone positioning and these require judicious use of pillows and silicone pads. Breasts and genitalia must be protected, and a head ring is