Dr. .Robert ShannonDesert Orthopedics

Rotator Cuff Repair Surgery Patient Information

Thank you for choosing Dr. Robert Shannon and his team at Desert Orthopedics. As your partner in health, we will work with you to make your surgical experience a positive one. Board certified and shoulder fellowship trained Dr. Robert Shannon, his Physician Assistant and Medical Assistant all work together to provide your optimal shoulder surgery outcome.

Before, during and after your surgery, our orthopedic team will work closely with you to meet both yours and ours desired recovery goals. We encourage you and your family's active involvement in this process. Please feel free to provide or raise any questions or concerns regarding you care throughout the course of your treatment. Please remember that your particular recovery may vary somewhat due to the differences in the severity of your injury or pathology, tissue quality, age, and general health.

At Desert Orthopedics, we want to ensure that your shoulder surgery experience is excellent. Many patients electing to proceed with shoulder surgery to treat their pathology and pain have questions regarding what will occur prior to, during and after their surgery. The first step is education! The information in this guide packet will assist you in understanding the shoulder surgery process and planning for your needs after surgery.

This pamphlet is designed as a source of reference and detailed written backup for your shoulder surgery and questions regarding the process.

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The Rotator Cuff

The shoulder joint is a ball and socket joint that connects the bone of the upper arm(humerus) with the shoulder blade(scapula).The rotator cuff is a series of four muscle-tendons that attach from the scapula to the humerus and control the motion of the shoulder and stabilize the shoulder joint. They enable you to lift and rotate your arm and reach overhead, and take part in activities such as throwing, swimming and tennis.

Rotator Cuff Injury and Symptoms

The rotator cuff can be injured or torn by a traumatic means from a fall on to an outstretched hand, elbow or shoulder or lifting a heavy object. The shoulder is immediately weak and there is pain when trying to lift the arm. The rotator cuff can also wear out and tear as a result of gradual, degenerative or chronic changes, resulting in gradual loss of motion, function and increasing pain.

The most common symptoms that patients note with rotator cuff problems are pain in the shoulder and radiation laterally in the upper arm. They may also note pain that frequently worsens at night with sleep. Patients with severe disruption to the rotator cuff have pain and are unable to lift their arm above shoulder level even with activities of daily living. Less severe damage to the tendons will simply produce pain with overhead activities.

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Rotator Cuff Treatment

Tendon inflammation or partial tears of the rotator cuff can be treated conservatively in their early stages. These treatments can include home exercise/stretching exercises, cortisone injection(s), physical therapy, anti-inflammatory medications, icing, and activity modifications of use of the arm and shoulder avoiding repetitive and strenuous activities and with use closer towards the body and below shoulder level. When conservative treatment measures fail to resolve symptoms, or full thickness rotator cuff tears are found on MRI or ultrasound, they may require surgical intervention.

This is an outpatient surgery that is performed arthroscopically through 3-4, one centimeter incisions, where the experienced surgeon, who is facile with arthroscopic techniques, skillfully uses the scope and specially-designed instruments to evaluate and repair the torn tendon(s). Depending on the size of the tear(s) and quality of the tissue, the tear is repaired using 1-4 anchors with attached sutures. The anchor(s) is placed to the bone and the suture(s) passed through the end of the torn tendon, and then tied together to close the tear and secure back down to bone. After the tendon is repaired, the arthroscopic skin incisions are closed with absorbable suture underneath the skin.

After the dressings are placed, a cold therapy pad will be placed on your shoulder which is easily held on with 2 velcro straps. This is used to help aggressively keep inflammation down after surgery. With less swelling, then the less pressure around the joint and tissues, means less pain, better circulation and improved healing.

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Potential Risks with Rotator Cuff Surgery

It is impossible to list every risk; therefore, this list includes the most common risks/complications associated with shoulder surgery:

1) Failure/Retear of repair: There is a 29% risk of re-tear of the rotator cuff after surgery. This may results from unanticipated re-injury, failure to follow restrictions and post-operative protocol, and tissue quality.

2) Infection: With any type of surgery the risk of infection exists. The risk of infection in shoulder arthroscopy is less than 0.5% for otherwise healthy patients. Treatment for this can be complex and include prolonged antibiotic use and repeated surgery.

3) Stiffness/Adhesive Capsulitis: This can occur after an injury or surgery where the shoulder capsule thickens, swells, and tightens due to bands of scar tissue that form inside of the capsule. As a result there is less room in the joint for the humerus, making movement of the shoulder stiff and painful with motion and even activities of daily living. Aggressive treatment includes Anti-inflammatories, cortisone injections, physical therapy for modalities and stretching to restore motion, which can take several weeks to months. When those more conservative treatments fail, then further surgery is required for manipulation of the joint for motion and arthroscopic release of scar tissue. Surgery is necessary in only 5-10% of cases.

4) Progression of Arthritis: If there is pre-existing arthritis in the shoulder, rotator cuff repair surgery can result in worsening of the arthritis. Due to this we try to avoid rotator cuff repair in cases of significant arthritis.

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Surgical Preparation for Rotator Cuff Surgery

Preparing for surgery: Having rotator cuff surgery is an extensive procedure. Our office staff will need to obtain

authorization from your insurance company before scheduling your surgery. Depending on your medical history, your surgeon may request that your primary care provider evaluate your general health before surgery and provide pre-operative clearance and recommendations.

Once we have obtained insurance authorization and, medial clearance if necessary, we will be able to schedule your surgery.

**Please, also refer to the the Surgery Pathway charts at the end of this packet for more detailed preparations required**

Preoperative visit:-You will have a pre-operative appointment with the Physician Assistant 10-14 days prior to your surgery. At that visit we will review your medical status and clearance from your primary care provider, discuss your medications, the actual surgical procedure, potential risks and postoperative expectations.

-Please bring a list of your current medications with you to this appointment. You will also find it helpful to write down any questions you may have and bring them with you as well.

-You will be given prescriptions for your postoperative medications at this visit.

-You will be given your postoperative shoulder immobilizer at this visit as well. It is recommended that you wear this an hour or two at different parts of the days prior to your surgery to become more familiarized with wearing it and functioning after your surgery.

-Following this pre-operative appointment, you will need to go up to the surgery center or hospital for completion of further paperwork.

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Surgical Preparation for Rotator Cuff Surgery(con't)

Medications:~If you are on blood thinning medications(Coumadin, Warfarin, Plavix) it must be discontinued prior to your surgery. You will need to check with your primary care provider before discontinuing this medication.~If you are taking Aspirin or anti-inflammatories(Advil, Ibuprofen, Motrin, Aleve, Naproxen, Meloxicam, Celebrex) please stop taking them 5-7 days prior to your scheduled surgery.~If you are taking any Narcotic medication these need to be discontinued two weeks prior to your scheduled surgery; please discuss this with us or your primary care physician.~Discontinue taking the following over-the-counter supplements one week prior to your scheduled surgery: Fish Oil or Omega-3, Vitamin E, Garlic, Ginseng, Ginko Bilboa

Attire:Wear loose and comfortable clothing the day of surgery.

~Sweat pants or shorts, Button-up shirts, and footwear that easily slips on/off such as slippers.~Leave all jewelry at home.~Leave contacts at home, but please bring your glasses with you.

Other:~Please do not wear make-up, lipstick, perfumes, lotions, or nail polish the day of surgery.~Please bring a list of your medications and dosages with you the day of your surgery.~Adjust around your home for safety, ease, convenience, and comfort knowing your post-operative restrictions with your surgical extremity being immobilized.~Get good night's sleep and stay well rested during the week leading up to your surgery.~Maintain a healthy diet.~Avoid tobacco and alcohol~Discontinue or significantly decrease any narcotic pain medication use 1-2 weeks prior to your surgery. This will make pain control post-operatively much mor effective.

***VERY IMPORTANT***~Unless otherwise instructed, Do Not have anything by mouth(food, liquids, gum, mints, water, tobacco) after midnight before your scheduled surgery

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Surgery Center/Hospital Course of Rotator Cuff Surgery

Anesthesia:You will receive general anesthesia during your surgery. The night before surgery you will be contacted by a member of Bend Anesthesia Group who will explain your anesthesia and address any questions that you may have concerning your anesthesia. On the day of surgery, your anesthesiologist will again review your anesthesia with you. In your pre-operative holding room, you will also be given a few medications which will significantly help post-operatively to address surgical pain, nerve pain and inflammation. After your surgery is completed you will be taken to the recovery room. Your surgeon will speak with your family members at this time. Your family should plan approximately 20-60 minutes after they speak to the surgeon before they will have the opportunity to see you.

Medications:You will be given 3-4 oral medications in pre-operative holding that will benefit you post -operatively with surgical pain, nerve pain and swelling. In recovery the nurses will work with you to keep your pain controlled, initially with IV medications, then advancing to oral medications. Your post-operative pain medication(s) will help with decreasing the level of pain but it is not meant to take the pain completely away. Some pain is expected(4-6 on 10 scale the first 24-48 hours).

Discharge:• This is an outpatient surgical procedure and you will be discharged from the recovery room to

home approximately 1-2 hours after your surgery is completed. You will need to have a ride arranged for home. You will also need to have arrangements made for a responsible adult to help you with care for the first 24 hours and further assistance for another 1-2 days.

• You will be given appointments for your first post-operative visit(10-14 days) and your 6 week visit.

• You will be given specific post-operative discharge instructions and restrictions and follow-up appointment cards for your 1st and 2nd post-operative visits at the time of your discharge.

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Discharge Instructions After You are Discharged Home

Anesthesia: The anesthetic medication(s) given to you during surgery will remain in your system for

approximately 24 hours. You may feel dizzy or lose your sense of balance. Your fine motor control may be changed and your judgement affected. Your reaction time for activities will be slowed. You may not recognize any of these changes. For the first 24 hours you should not be alone; arrange for a responsible adult to remain with you during this time, and available for assistance for another couple of days.

Diet:• You may resume your regular diet as tolerated. It is recommended you stick with a bland diet

the first day with small. frequent portions, not 'meals'.- Chicken, rice, mashed potatoes, soup, etc... with few spices- Clear fluids: water, 7Up, Sprite, Gatorade, Ginger Ale, apple/cranberry juice

• Include plenty of fluids to maintain hydration, as decreased activity and pain medications can tend to cause constipation.

• Maintain a well balanced diet

Medications:• You were given a prescription for your post-operative pain medication at the time of your pre-

operative visit. It is recommended that you take this medication as prescribed for the first 24 hours after you surgery, then as needed for pain management. Shoulder surgery is painful. Your post-operative pain medication will help decrease and control your level of pain, but is not meant to take away the pain completely. Some pain is expected for the first 7-10 days.

• It is your goal to gradually decrease the use of the pain medication. Most patients are off their pain medication in four to six(4-6) weeks. These medications and refills will be given during this time(if needed) per Dr. Shannon's Post-Operative Pain Medication Protocol that is included in the information packet.

• You should not drive, use potentially dangerous appliances/equipment, make any major decisions, or drink any alcohol while your are still taking pain medications.

• Pain medications can cause drowsiness, nausea, itching and constipation. Take your pain medication with food to help decrease nausea.

• Any constipation may be addressed with over-the-counter stool softeners such as Colace, Ducolox, Miralax. It is important to drink plenty of fluids to maintain hydration as well.

• Do not consume alcohol while taking any narcotic pain medications.

Pain:• Shoulder surgery is painful. Some pain is expected for the first 10-14 days.• Some pain may be a result of over-activity. When you develop pain or swelling:

---Rest, Ice, Elevate• Sitting and sleeping in an recumbent/reclined position(Laz-E-Boy/ bed wedge) with one or

two pillows under your elbow to help keep your arm level with your belly will be of benefit when at rest or sleep for the first several days after your surgery.

• If the pain does not subside to a tolerance with rest, ice, elevation then take the pain medication prescribed for you.

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Discharge Instructions After You are Discharged Home(con't)

Swelling: • Some swelling in your operative extremity is normal and will decrease over time. The goal is

to minimize swelling to create less pressure around the joint and tissues, which means less pain!

• You will be fitted after surgery with a cryotherapy(ice) machine. A thin pad fits over your shoulder and is held on easily with two Velcro straps. Tubing connects the pad to a cooling machine which circulates ice water through the pad.

- use this machine whenever you are at rest several times a day, one hour on/one hour off, then 2-3 times a day for the first couple of weeks and as needed.

• When swelling occurs, Rest, Ice and elevate the extremity in your reclined position. To assist with decreasing swelling and stiffness move your fingers and wrist frequently while in immobilizer. You may also remove your wrist from the immobilizer to gently bend and straighten your elbow several times a day.

Wound Care:• Keep your post-surgical dressing clean and dry.• You may remove your dressings after three(3) days. At that time you may shower and allow

soap, water and shampoo to run over the shoulder. The incisions do not need to be covered.• Do not soak the incision areas under water until 2 weeks after your surgery.• Do not apply any ointments, Neosporin or lotions to the incision sites.• There are no sutures to be removed. They are absorbable and under the skin.

Activity:• Your surgical extremity is to remain in the shoulder immobilizer at all times, except with

showering. • You may come out of the wrist aspect of the immobilizer and work on gentle elbow range of

motion frequently throughout the day.• No lifting, carrying, pushing or pulling with the surgical extremity.

Therapy:• There is no therapy the first six(6) weeks post-operatively. You will have to remain in

your immobilizer at all times, except with bathing. There is no lifting, carrying, pushing with your surgical extremity during this time.

• At your six(6) week post-operative visit you will be given instructions and a handout for a number of exercises you will begin and continue for six(6) weeks. You should do these 2-3 times a day during this time.

• Also during the second six(6) week post-operative period you may gradually progress to using the extremity with your functional activities of daily living.

*No lifting anything heavier than 1-2 pounds during the second six(6) weeks*

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PRE-OPERATIVE- Shoulder Surgery Pathway

3 weeks pre-op

2 weeks pre-op

One week pre-op

Day Before Surgery

Day of Surgery

Medication/Diet

-Maintain a well balanced diet-Discontinue any pain medications

-Keep a well balanced diet-Monitor blood sugars(if diabetic)-Prepare/purchase easy meals-Reduce alcohol

-Keep a well balanced diet-Stop blood thinners and anti-inflammatory medications -Get prescription(s) filled

-Follow instructions given by surgeon and pre-admissions-Nothing by mouth after midnight

-Nothing by mouth-May brush teeth/rinse/spit-Take medications only as instructed

Education -Positive attitude for a successful surgery-Review patient info packet

-Positive attitude for a successful surgery-Review patient info packet-Surgeon preop office visit-Pre-admission visit with Surgery Center/Hospital

-Positive attitude for a successful surgery-Review patient info packet

-Positive attitude for a successful surgery-Review patient info packet-One business day before surgery, surgery preop will call with surgery time

-Positive attitude for a successful surgery

Respiratory/Skin care

-Avoid tobacco -Avoid tobacco -Avoid tobacco -Avoid tobacco and alcohol-Call surgeon if you're ill or have skin breakdown/rash-Remove all nail polish

-No tobacco-No make-up/lotions/perfumes

Other preparation

-Stay well rested-Arrange for someone to stay for 1-2 days when you return home

-Stay well rested-Review checklist-Make necessary plans to arrive on time for surgery-See other physicians as ordered by surgeon or primary doctor

-Stay well rested-Review checklist-complete all diagnostic tests(if ordered)-Arrange home for safety and comfort

-Stay well rested-Get a good nights sleep-Review checklist-Layout clothing, shoes, for surgery

-Bring shoulder immobilizer to surgery

Equipment -Shoulder immobilizer:you will receive at preop visit

-wear shoulder immobilizer 1-2 hours at different parts of the day to better accustom for after surgery-freeze 4-6 twelve oz. plastic bottles for ice machine postop

-Bring shoulder immobilizer to surgery

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POST DISCHARGE- Shoulder Surgery Pathway

Week One Weeks 2-6 Weeks 6-12

Medications -Pain managed with pain pills and Pain Medication Protocol(attached)-OTC stool softener while on narcotics-Resume home medications

-Pain managed with pain pills and Pain Medication Protocol(attached)-Over-the-counter analgesics such as Tylenol and non-steroidal anti-inflammatories

-Over-the-counter analgesics such as Tylenol and non-steroidal anti-inflammatories

Breathing Exercises -10 Slow deep breaths every hour when awake for first 3-5 days

Activity -No use of surgical extremity

-No use of surgical extremity

-Activities of Daily Living as tolerated-No lifting heavier than weight of phone receiver with surgical extremity

Therapy -None -None -Forward elevation, table glides, wall walk, pendulums as instructed

Recovery Progress -Visits post-operative to surgeon in approximately 10-14 days, 6 weeks, 3 months, 6 months, one year

-Visits post-operative to surgeon in approximately 10-14 days, 6 weeks, 3 months, 6 months, one year

-Visits post-operative to surgeon in approximately 10-14 days, 6 weeks, 3 months, 6 months, one year

Wound Care -Keep dressing clean and dry for first 3 days-May remove dressing postop day#3. At that time incision may be open to air, does not need to be covered in shower-No ointments/lotions on incision until it is a scar

-No soaking of incisions until it looks like a scar-Once a scar, you may do gentle massage and use vitamin E oil or lotions if desired

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Dr. .Robert Shannon Desert OrthopedicsRotator Cuff Repair Surgery Patient Information

PATIENT PRESCRIBED PAIN MEDICATION PROTOCOL

*unless authorized by MD

Medication schedules:

Schedule II: Oxycontin, MS Contin, Oxycodone, Percocet, Percodan, Dilaudid, Tylox

Schedule III: Hydrocodone, Norco, Vicodin, Lortab, Tylenol with Codeine

Anti-Inflammatories: Ibuprofen, Motrin, Advil, Aleve, Naproxen, Diclofenac, Voltaren, Celebrex, Meloxicam

Non-narcotic Analgesics: Tramadol, Acetaminophen, Tylenol

*** ALL Prescription refill requests require 48 hour notice******No refills will be made after noon on Fridays or on Weekends***

Weeks 0-2 Weeks 3-6 Weeks 7+

-Joint Replacements-Rotator Cuff/Labral Repair -Fractures

Schedule II -with one refill

Schedule II -No refill*Schedule III -with one refill

No Schedule IISchedule III -no refill*Tramadol -one refillAnti-inflammatoriesTylenol

-Knee/Shoulder Arthroscopies

No Schedule IISchedule III -with one refill

-No schedule IISchedule III -No refill

No Schedule II or IIITramadol -No refillAnti-inflammatoriesTylenol

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