Arthoscopic Rotator Cuff Repair
Dr. Ward Oakley Shoulder Patient Information
The following information is designed to help you make a decision on whether you are ready to have surgical correction of your shoulder condition, a torn Rotator Cuff.
Please read this completely and be prepared to ask any questions when you return.
ARTHROSCOPIC ROTATOR CUFF REPAIR
PATIENT INFORMATION – Ward Oakley, MD Shoulder Patients
Arthroscopic rotator cuff repair is a very successful procedure and has completely replaced the open (large incisions) surgical approach in the treatment of patients with a torn rotator cuff. Arthroscopic shoulder surgery is performed on an outpatient basis. This surgery is performed through a few small (<1cm) incisions in the front, side and back of the shoulder. Through these small holes an arthroscope is inserted that allows the surgeon to see throughout the inside of the shoulder joint. Special arthroscopic instruments are utilized through the other holes to perform the necessary surgery of correcting/repairing the torn rotator cuff and other damaged tissue.
Arthroscopic shoulder surgery usually takes about 1 hour to perform but may take longer for the more complex Rotator Cuff repairs. However the total time that the patient may be away from the family could be 3-5 hours because of the time needed to prepare the patient for surgery, perform the nerve block, prepare and position the patient in the surgical room, the operating time, and finally the time in the recovery room. Occasionally patients have a significant medical condition (severe sleep apnea, cardiac conditions, etc.) that will require that the patient to be closely monitored in a hospital overnight.
Anesthesia for shoulder arthroscopic surgery is a combination of a nerve (scalene) block and general anesthesia. The Scalene Nerve Block that most patients receive is designed to minimized the amount of anesthesia they receive during the surgery and to keep the shoulder and arm numb and pain free for 12 hours or more after the surgery. Because the anesthetic from this nerve block will eventually wear off it is important that the patient take the medicines prescribed for them regularly for the first day or two.
Surgery: The surgical incisions will be closed with sutures or staples and covered with simple large band aids before you are sent home. Commonly there is a perfuse drainage of water from these surgical incisions that persists for about 12 hours so a large pad is usually helpful to absorb this. You will be given extra bandages to change them if so desired. A sling/abduction pillow will be applied to that arm to protect the rotator cuff and other repaired tissue. It must NOT be removed before your first follow-up visit. Other than what we dress you with, changing or putting on a shirt, a bra, or a t-shirt is NOT permitted before your first follow-up visit. Changing the sling or removing it to dress in an undershirt or undergarment puts your surgical repair at risk of tearing loose. Showering is NOT permitted before your first follow up visit. The staples will be removed from the incisions and covered with simple pieces of tape at the first follow-up visit, 4-7 days after surgery. These do not need to be changed but should be removed in a week to 10 days. Showering and dressing techniques will be given to you on your first follow-up visit.
POTENTIAL COMPLICATIONS:
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As with all surgeries there is the risk of infection at the operative site. This is a rare occurrence of less than 1%. Antibiotics are administered prior to surgery as a preventative action.
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The development of a blood clot in the venous system of your leg or arm, also known as Deep Vein Thrombosis (DVT) is a potential complication. Again this is a rare occurrence of less than 1% in arthroscopic shoulder surgery. Specific precautions are taken to minimize this uncommon risk.
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Unfortunately, the most frequent complication is failure of the rotator cuff repair to heal. This is usually related to early motion, poor tissue quality, increased age, or deficient bone quality. We must allow the repair to at least begin to heal prior to beginning to stress it with use. This is the reason why early motion and the use of early aggressive physical therapy must be avoided. If the tissue is not allowed to heal from the start it will not heal later. The 10% Rule: healing occurs at 10% per month. It takes at least 10 months for the tendons of the Rotator Cuff to heal strong enough for near normal activities. This can be very frustrating for the patient: waiting for the healing process to mature. Prepare yourself for a slow, gradual recovery.
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Nerve injury from either the anesthetic scalene block or stretch injury during surgery is a rare possibility at about 1% as reported in the medical literature. Such injuries usually are temporary and resolve in the first few weeks to months.
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Your overall general health is also important in good tissue healing. Smoking is not good. Smoking has been shown to be one of the most significant factors associated with failure of a rotator cuff to heal. Maintaining a good blood pressure and normal blood sugar levels are very important. Medical conditions such as Diabetes, Hypertension, & Kidney Disease need to be closely monitored by you & your physician.
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Psychologically the prolonged recover period can be very stressful. Frustration with not returning to normal function and activity in a short time can be very depressing or anxiety provoking. This stress can lead to clinically evident depression/anxiety. Interestingly patients who are convinced that “they heal faster” than others or feel that they have very demanding work schedules commonly fall prey to this. Patients with a history of depression/anxiety are also easy to become more depressed or anxious. Please be prepared for a slow recovery. It seems that between 6-16 weeks is when most patients struggle with this frustration. Please remain open to us talking to you about this issue as we follow you during your recovery.
COMMON CONCERNS AFTER SURGERY:
Sleeping: A recliner is strongly recommended for 4 weeks after surgery. Some patients can get comfortable on a couch. Keeping the head elevated and using pillows for propping the operated arm provides comfort. Most patients are able to get back into their bed in about a month. Sleeping on the operated side is to be avoided for up to one year after surgery. It is normal for you to have difficulty sleeping for a couple of weeks after surgery. Sleeping for spans of only 2-3 hours is common. Sometimes having more than one place to sleep (i.e. recliner, couch, and a bed with many pillows) allows for a position change that can improve comfort and enhance sleep. It’s important to maintain a normal routine for “going to bed.” As you become more active, you will sleep better. Not being able to sleep comfortably and for extended periods of time is a common complaint after this surgery.
Pain: Prescriptions for pain medication will be provided for optimal pain control. These strong medications should be used regularly the first two (2) days and then as needed thereafter. A list and description of these will be provided. Please read this information before your surgery. The frequency by which these medicines are needed should decrease about 3 days after the surgery. Occasional use of the narcotic pain medicine may continue to be needed for several weeks, most commonly at night.
Self Care/Loss of use of Dominant Arm: If you are Right Handed (Dominant Arm) and your right shoulder needs surgery then loss of use of that arm should be a concern. This is particularly a concern for Personal Hygiene: hair, brushing teeth, make-up, etc. You will not be able to perform these tasks for several weeks! It is strongly recommended that you practice using your other arm (non-Dominant Arm) for performing these tasks, prior to your surgery.
Websites of Interest:
http://orthoinfo.aaos.org/topic.cfm?topic=a00406
http://www.webmd.com/pain-management/picture-of-the-rotator-cuff
YOUR SHOULDER TEAM:
Ms. Connie B. Tighe, NP is Dr. Oakley’s specialized shoulder assistant. She is responsible for assuring that you are ready for surgery. She will be there on the day of your surgery. Connie will be primarily responsible for your care after surgery, in collaboration with Dr. Oakley.
Dr. Ward S. Oakley, Jr. will perform your shoulder surgery. He is always assisted by Ms. Connie Tighe, NP or Ms. Kristi Blatz, PA. Arthroscopic shoulder surgery is technically demanding and is best done with a skilled and knowledged team. After surgery Dr. Oakley will see you at your first post op visit and thereafter by both Dr. Oakley and Ms. Tighe, NP in the Oakley Shoulder Class.
SHOULDER CLASS:
Dr. Oakley has a Shoulder Class that meets every Thursday from 2-3 PM that is focused on the recovery of patients having had a Rotator Cuff Repair. Weekly attendance is necessary for full and successful recovery from surgery. Exercises, pain management, prescriptions, work/activity restrictions, etc. are discussed and reviewed. For more information call: (910) 295-0209.
DECISION FOR SURGERY
Once you have reviewed this literature and want to proceed with scheduling your surgery then please contact Ms. Mary Huff at 910-235-2963 or by email at mhuff@pinehurstsurgical.com. She will discuss with you the possible dates and the necessary steps to be completed to prepare you for that surgery. Important concerns are medical insurance approval, benefits, and expected deductibles, and the need for a medical evaluation and lab testing.
INSURANCE/COSTS
We will be responsible for contacting your insurance company for prior authorization or pre-certification for your surgery. It is important for you to know your benefits as well as your out of pocket expenses and co-pays. Bills for this surgery will include a surgeon’s fee, anesthesia fee and facility (where the surgery is performed) fee. We at Pinehurst Surgical have no control or responsibility for the anesthesia charges or facility charges.
*Please be aware that because it takes a year for a surgical repair of a rotator cuff to achieve full recovery we follow all of our patients for at least that length of time. We want you to be aware that almost all insurance payments for an arthroscopic shoulder surgery includes the charges/costs associated with clinic/office visits after that surgery for the first 90 days from the day of the surgery. Office/clinic visits after those first 90 days then become a routine office visit charge. We try to minimize
those return office/clinic visits after those first 90 days.
MEDICAL EVALUATION
A complete medical evaluation is required prior to any surgery. Unfortunately some patients have medical conditions that may require a specific Medical Clearance from their personal physician or from another medical specialist such as a Cardiologist. We will assist as needed, but it is important to understand that it is your responsibility, as the patient, to be sure that the necessary Clearance be scheduled and completed prior to returning for the final pre-operative visit 2 weeks before the date of the surgery.
WORKER’S COMPENSATION
If this shoulder condition of a rotator cuff tear is filed or is to be filed under Worker’s Compensation then approval from the appropriate Insurance carrier will be required prior to proceeding.
After surgical repair of a Rotator Cuff Tear, work restrictions that limit your use of this shoulder and arm will be reflective of the surgery needed to treat the work injury. Under NC statutes the employer has the option of accommodating such work restrictions or allowing you to remain out of work until an appropriate time of recovery.
Rotator cuff repairs generally take 1 year to reach Maximum Medical Improvement (MMI) and be released from the necessity of medical follow up.
MAXIMIZING YOURSELF FOR RECOVERY
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STOP NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) is a groups of medicines such as Motrin, Advil, Aleve, Ibuprofen that are purchase over the counter or prescription medicines such as Mobic, Celebrex, Voltaren etc. that are prescribed for the treatment of arthritis and pain. They should be stopped two weeks before shoulder surgery and be not resumed for use until 6 weeks after surgery after shoulder Rotator Cuff surgery. As a group and Celebrex specifically have been found to inhibit the healing process of tendons and ligaments in the early stage.
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STOP SMOKING. It is well documented that smoking impairs tissue healing for shoulder rotator cuff repairs and therefore should be avoided.
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EXERCISE. Exercising prior to surgery is beneficial for two reasons. One is to increase the range of motion of the shoulder which then helps minimize or prevents the stiffness of the shoulder after shoulder surgery. The second is to strengthen the muscles (deltoid muscles) that act to support or compensate for the deficient or weakened rotator cuff muscles. A strong deltoid muscle helps the speed and functional recovery of the shoulder.
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SELF CARE. Practice using your other arm for all personal hygiene activities: Hair, Teeth, Make-up, etc.
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RECLINER. Having a comfortable recliner that you the patient can sleep in is a near absolute necessity. Be sure that the hand control for the recliner is not on the same side of the recliner as the shoulder being operated.
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VITAMINS. In the absence of a severe deficiency there is no scientific proof that a particular supplement or vitamin will make you heal faster. However it is not uncommon for people with normal diets to be low in certain vitamins especially vitamin D, for which we generally recommend 2000 units daily.
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CLOTHING
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It is strongly suggested that you bring a button-up-the-front shirt that is several sizes bigger than normal. We would suggest a Man’s Size XXX. We will dress you in this after the surgery. Please bring such a shirt with you on the day of surgery. This usually works best for the first week after surgery. For those patients that like to wear a T-shirt or similar undergarment we suggest that you bring one that we can adjust (cut the sleeve off) and dress you with after the surgery.
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Pants. We would suggest a loose pair of pajama type pants, shorts, or sweat pants to wear home after the surgery.
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ACNE SOAP. Washing your shoulder and arm pit for two days before surgery with a generic acne soap will minimize skin bacteria and therefore reduce the risk of an infection. This should be done during your regular shower/bath.
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DVT (Blood Clot): Aspirin 81mg/day (baby aspirin) to help prevent a blood clot from forming during/after surgery. If on another blood thinner please clarify it use or stoppage prior to surgery with Dr. Oakley or Ms. Connie Tighe, NP.
CHECK LIST (for the day before surgery)
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NO FOOD after Midnight. Water only for taking necessary pills.
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STOP NSAIDs.
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TIME to arrive for surgery.
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BATHE with Acne Soap tonight.
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MEDICINES to be taken in the morning.
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CLOTHES to bring to wear after surgery: 3X shirt & T-shirt.
ARTHROSCOPIC ROTATOR CUFF REPAIR SUMMARY & UNDERSTANDING
I have read and understand the information on rotator cuff repair. My questions have been answered. The following key points are very important to maximize my care and expected recovery:
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I understand the 10% rule: That the healing of a rotator cuff tear is very slow, only getting better at a rate of 10% per month. The sling will be worn for 4-6 weeks. It takes 9-12 months for a Rotator Cuff to heal!!
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I understand that I am not to use this arm (the entire upper extremity) until specifically instructed. This means no use of this arm for work, driving, eating, or personal hygiene until the healing process has progressed appropriately. (You should practice using the other arm for personal hygiene issues before the surgery.)
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I understand that I am not to plan to work for 2 weeks and will have limited use of my hand and arm for 6 weeks. I will not plan to travel for 12 weeks.
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I understand that I will be individually instructed in appropriate exercises to perform at each return visit to The Shoulder Class after the surgery.
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I understand that I cannot remove my brace until I return to Pinehurst Surgical for my first follow up visit and I am not to try to put a shirt on underneath the brace until that first follow up visit.
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I will bring an oversized, button up shirt to wear immediately after surgery. If I desire to wear a t-shirt or similar undergarment under my shoulder brace I will bring that as well.
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Having a recliner to rest & sleep in at home will maximize a comfortable recovery.