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Arthroscopic and Open Shoulder Surgery
Arthroscopic shoulder surgery (also called microsurgery) is performed on the shoulder for a variety reasons, among the most common is repair and/or decompression of the supraspinatus or rotator cuff (rotocuff) tendon of the shoulder. It is also used to remove an arthritic end of the collarbone, or repair a dislocating shoulder.
Pre Surgery Preparation
A complete health assessment and patient profile is given to an anesthesiologist, who is a doctor of medicine experienced in matching the proper anesthetic and dosage to the patient.
Patients are encouraged to fill prescriptions for pain and other medications on or before the day of their surgery, as pain following arthroscopic surgery can be moderate. Pain medication is prescribed by Dr. Sanders and administered to the patient in the operating room.
At the Sanders Clinic, shoulder surgery patients are given the benefit of multimodal analgesia. By attacking the pain through several different pathways, fewer narcotics will be necessary, and subsequently, the negative side effects of narcotic use can be diminished or eliminated. These medications include an anti-inflammatory such as Meloxicam, a nonnarcotic analgesic such as Tramadol, acetaminophen, also known as Tylenol and gabapentin which calms down peripheral nerve pain. These medications are taken around the clock. The need for a Class 3 narcotic analgesic, such as hydrocodone, is drastically diminished so fewer side effects such as effects such as nausea and/or constipation occur. Phenergan is prescribed to help with nausea. Taking two Tylenol every four hours is a good alternative.
And Tylenol PM (a preparation that includes benedryl) is encouraged over other medications in the event of sleep disturbance, which is common after such procedures. Ambien, which is also prescribed, is a stronger sleep aid.
Too often patients come in for surgery, particularly outpatient surgery, having had very little to drink and subsequently become dehydrated following the surgery. It is important that patients rehydrate following a surgical procedure – consuming sufficient quantities of water and a sports aid drink containing sugar and electrolytes. Proper hydration is the key for the body, particularly one in recovery.
An Aquacel® dressing may be applied over the wound. This medicated dressing is impregnated with Silver which is a potent germ killer. It will also serve as a reservoir for bloody drainage, and should be maintained in place for one week. During the first seven days. The cuts should be washed with a 50/50 mixture of Hibiclens® (4% Chlorhexadine Gluconate) and water and used as soap. After showering pat the operated area dry to keep the Aquacel® from coming off. Occasionally, it will come off before seven days. When that happens, the wound should be washed twice daily with Hibiclens® and Triple Antibiotic ointment placed on the open areas.
A Cryo/Cuff® is placed over the dressing, delivering cold therapy as well as compression. With the exception of showering, it should remain on for one complete week.
During surgery, antibiotics are administered by vein to prevent the risk of infection. No other antibiotics are needed, but patients are encouraged to follow all instructions regarding the care of their wound and monitor it closely to further reduce the risk of infection.
If a portion of the surgery was performed through an open incision, the wound may be closed with nylon sutures. The sutures should be left in for three weeks or until determined by Dr. Sanders. Occasionally, there is a small amount of drainage from the wound - a normal bodily response and NOT an infection.
Unlike the knee, where nearly all surgical procedures demand immediate motion, some shoulder procedures will require a period of immobilization.
Subacromial decompression, and/or an excision of the distal clavicle
For patients who have had a subacromial decompression, and/or an excision of the distal clavicle, the sling may be discarded upon arrival home or on the first postoperative day. He or she may start using the shoulder as if a simple sprain or strain. Patients then begin Codman exercises the first postoperative day. These are done by removing the arm from the sling and resting the elbow straight. The torso must be bent forward and nearly parallel to the floor (bending maximally at the hips and lumbar spine).
When this is achieved, the arm hangs perpendicularly (at right angles) to the floor. The patient makes small then increasingly larger circles with their arms. This mobilizes the shoulder and prevents stiffness. In another exercise, a patient places a broomstick in their hands and uses the opposite side to help raise the operated side such that your arm is over your head, like a child raising his hand in class. Then you should bring the arm down and then repeat 10 times. This should be done 6 times per day. After a few days, you should perform this exercise without the broomstick. Dr. Sanders or your Trainer will instruct you in the remainder of the exercises. The patient returns for their first postoperative visit one week following the procedure, where Dr. Sanders evaluates the progress and recommends a course of shoulder exercises with a Thera-Band® to strengthen shoulder flexors, abductors, external rotators, and internal rotators. The use of the Thera-Band® is also emphasized in order stretch into internal rotation. Other exercises with hand weights help strengthen the scapula rotators. Three sets of 12 repetitions of each exercise are necessary each day. These exercises should be done regularly for at least one year.
Post-Operative Rehabilitation for Commonly Done Procedures on the Shoulder
Surgery for Shoulder Instability
Patients who have undergone arthroscopic or open surgery for labral repair are best to maintain their arm in the Cryo/Cuff® for the first week, and then the UltraSling® for the next five weeks. The sling should be worn at all times except for showering, during which time the arm can be moved away from the body just enough to wash the arm pit. Over the past few years we have learned that, unlike the knee, the ligamentous structures of the shoulder heal best with six weeks of immobilization. After that time motion is begun, first passively and then actively. Strengthening is begun at three months and return to sports can occur as early six months.
Although it seems contra intuitive, patient who have undergone the Latajet procedure, an open surgery, are far less restricted in the early period. After a week of immobilization to allow for early inflammation to resolve, the Cryo/Cuff® and/or UltraSling® can be discarded, and patients can use their arm for ordinary activities of daily living, avoiding lifting any object heavier than a soft drink can for six weeks. In most cases, motion will return on its own, but occasionally a few sessions with the therapist will be necessary. These athletes can return to sports by three months.
It is becoming clear that the advantages of the Latajet procedure over commonly done arthroscopic suture repair are considerable. The concept of “Minimally Invasive” surgery may need to be rethought. Should it be based solely on length of the wound or length of time away from what you love to do? This is an individual decision that varies with the patients desires, and perhaps more importantly with surgeon’s skill set.
Arthroscopic Assisted Rotator Cuff Repair
Similar to the issues involved with arthroscopic labral repair, the most up to date research indicates that, because of the special nature of the rotator cuff tendons' insertion into the humerus, immobilization of the shoulder in a Cryo/Cuff® and/or UltraSling® is the best way to manage the repaired rotator cuff. Following eight weeks of rest, passive exercises leading up to active exercises are begun. Return to sports is reasonable at six months, though specific exercises must continue. Improvement in strength and range of motion will continue during the entire first year.
Most commonly, tenodesis of the long head of the biceps tendon is performed in conjunction with a rotator cuff repair, and rotator cuff rehabilitation takes precedence. Occasionally, it is performed on its own. In these cases, the rehabilitation can be a bit more aggressive. Patients are immobilized for the first week in the Cryo/Cuff® and/or UltraSling®. After the first week, they are started on a program of active and active assisted exercises performed with the elbow bent to 90 degrees several times per day. After exercise the sling is replaced. It may be discarded after six weeks, at which time a more aggressive program is started. Return to sports is reasonable in three months.
Repair of Acromioclavicular Dislocation/Separation and Open Reduction/Internal Fixation of Fractures of the Clavicle
Most commonly, this procedure is not associated with other procedures in which a conservative rehabilitation protocol is required. Our patients are started on active and active assisted motion the day after surgery. Most can discard the Cryo/Cuff® and/or UltraSling® within a week, and use the arm for activities of daily living, remembering not to lift anything heavier than a soft drink can for the first six weeks. Rehabilitation can become a bit more aggressive in the second six weeks, and return to sports at three months is the norm.
Fracture RepairMost shoulder fractures occur in older or infirm patients who have osteoporosis (weak bone). Smokers and diabetics are particularly prone to these fractures. Weak bone limits the effectiveness of any type of metallic fixation. Simply put, a chain is only as strong as its weakest link. Strong screws, plates, or prostheses, placed into weak bone, leads to a weak construct. For this reason a conservative protocol is necessary. Patients are immobilized in the Cryo/Cuff® and/or UltraSling® for the first six weeks. Based on their post-operative fracture healing, as seen on X-ray, they may be started on active assisted and active exercises after six weeks. The rehabilitation process is slow and more dependent on the patient’s general health than any other single variable. Because some element of nerve injury is present in 80% of patients, full recovery is not expected for two years, although reasonable function is expected long before that.
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