Before Your Surgery

 Understanding the procedure and outcomes

Knowledge about what surgery will be performed and what the ultimate goals are is clearly important. Although they are discussed with your surgeon, it is not uncommon to think of additional questions following your appointment, or to be so nervous that you have a hard time remembering the specifics of what is discussed. If a number of questions arise before your surgery, it is best to make a follow-up appointment prior to your operation as there will be more opportunity to discuss things. The surgeon’s administrative assistant, or secretary, is also a valuable source of information should quick questions arise.

Another source of information is the patient section of our website: www.smortho.ca. Information about the following procedures will be added online in time:

  • Arthroscopic Rotator Cuff Repair
  • Arthroscopic Long Head of Biceps Tenotomy
  • Arthroscopic Decompression
  • Arthroscopic AC Joint Resection
  • Shoulder Stabilization Procedures
  • Shoulder Arthroplasty (Replacement)

 

Medical Clearance

Regardless of your health status, steps must occur prior to your operation to help ensure the procedure can progress safely. Individuals will be given paperwork for their family physicians to complete prior to an operation. Those undergoing major operations or those with notable medical conditions will be sent to our pre-operative anesthetic care clinic, where the physicians responsible for making your comfortable during the surgery will discuss your care plan. They will also inform you what medications to stop prior to your surgery.

 

Getting Ready

There are many things to consider in the weeks leading up to your surgery. As everyone’s given lifestyle and living environment is different, it would be impossible to be able to plan for absolutely everything. However, here is a list that applies to many of our patients before the operation:

  • Support at Home: it is critical to have someone who is able to help with day to day tasks for 1-2 weeks following a shoulder operation. For safety, we require someone to be with you at home immediately following the operation.
  • Work/Volunteering: time required off work or similar activities depends on the type of procedure performed and your line of work. Some people are able to return to work in a sling at 1-2 weeks on modified duties (i.e. desk work), while others require 3 months before they are able to return. It is important to discuss return to work with both your surgeon and your employer, and to consider if any modifications may allow you to return to work earlier.
  • Food: Having access to nutritious meals with minimal preparation or clean-up will be useful regardless of your stage of recovery. Consider freezing two weeks’ worth of extra meals to ensure you have both the time and the energy to recover while in a sling following surgery.
  • Pain Control: While no surgery is painless, we strive to make the process as pain-free as possible. We utilize a multi-modality approach to pain control that includes nerve blocks and multiple oral medications. Despite this approach, the first two weeks following shoulder surgery can be challenging, and all patients are counselled on what to expect. Following surgery, you will go home with an instruction sheet and a prescription for pain medications. Given the clear ‘opioid crisis’ facing North America, our goal is to progress patients off narcotic medication as quickly as possible.
  • Sleeping: most people find it most comfortable to sleep upright or ‘semi-reclined’ in a recliner chair. This allows gravity to continue to pull down the shoulder, which is more comfortable during the post-operative phase. Expect to prefer to sleep in a recliner chair for upwards of six weeks. Sleep becomes increasingly easier and longer-lasting between 6 weeks and 3 months.
  • Additional Recovery Aids:
    • Slings: The hospital provides basic slings (for a small fee) following shoulder surgery. Some patients prefer to acquire more advanced slings for improved comfort. Slings may be covered by private health care insurance, and we recommend clarifying your coverage to help limit out of pocket expenses. Your surgeon’s office can direct you to local providers so that fitting may occur before an operation.
    • Cryo-compressive Devices: shoulder wraps which deliver both compression and ice around the shoulder are preferred by some of our patients. Studies utilizing these devises in shoulder surgery continue to be conducted. Currently, we believe these devices help with immediate post-operative pain and swelling, but are not a requirement for successful recovery following shoulder surgery. Your surgeon’s office can direct you to local providers so that the device is ready to be applied immediately following your operation.
    • Bath Chair: You may begin to shower post-operative day 2-5 (depending on your level of comfort). As my patients are still taking narcotic medications, we prefer our patients have access to a bath chair so they can sit down and thus decrease the chance they sleep and fall in the shower. A plastic lawn chair can serve the same purpose. Expect to need this aid for 2-6 weeks.
    • Bandages: We recommend having access to 20 small four-sided adhesive bandages (i.e. Band-Aids) for arthroscopic procedures, and 5 longer adhesive bandages for any surgeries performed in an open fashion. This will allow you to change your dressings every other day until the sutures/staples are removed.

 

Day of Your Surgery

 NPO

Nil Per Os’ or NPO is medical terminology for ‘nothing to eat or drink prior to surgery’. These restrictions apply starting the midnight before your operation. The daily medications you were instructed to take before surgery can be done with a very small sip of water. Eating or drinking before your operation will likely delay or outright cancel your surgery.

Scheduling

You will be instructed to phone the hospital the day before your surgery to confirm the time of your procedure. Instructions will be given to tell you when and where to arrive. Please note that in very rare instances medical emergency may require us to delay or postpone your surgery. If this were to occur, we greatly appreciate your understanding as the surgical team responds to time-sensitive medical conditions.

Check-In

Upon your arrival, you will be registered at the hospital. An Intravenous will be started, and appropriate testing arranged. An initial safety check performed by our nursing staff will be undertaken, your personal belongings stored, and your clothes changed to gowns necessary to maintain sterility in the operating room setting. Once this is complete there may be additional waiting, so please consider bringing a book or other form of entertainment.

Holding Area

When your surgery is roughly 30 minutes from starting, you will be transported to the ‘holding’ area. Here you will speak to the surgical team that will participate in your care – your surgeon, your anesthetist, and one or more nursing staff. You may be asked similar questions several times – such repetition is necessary to avoid critical errors which may impact your health.

Block Room

Depending on the time of day and the need for specialized local anesthesia before surgery, you may be transported to a ‘block room’ prior to the operating room.  Here, you will receive a special type of anesthetic designed to help control your pain during and after your surgery.

Operating Room

When the operating room is ready you will be transported there. Given the critical importance placed on sterility, please do not touch anything beyond the surgical bed. Your surgeon will perform a ‘time-out’, which confirms the side of the surgery and the procedure you will be having. Although your surgeon and anesthetist will likely be using phrases or jargon that may sound foreign, the process is designed to ensure the entire team is aware of important aspects of your surgery and medical history. At this point you may receive a block (if not already given as per above) and will be put off to sleep.

PACU

Following your surgery you will be transported to the PACU, or Post Anesthetic Care Unit. Here nurses will closely monitor you to ensure you have emerged from anesthesia safely and that your pain is controlled. The medications used during anesthesia can cause nausea/vomiting, and the team strives to manage both this and pain. Please note that anesthesia commonly causes forgetfulness, and it is not uncommon for people to forget much or all of what occurs in the PACU.

Day Surgery

As you prepare to leave hospital, you are transported to Day Surgery. Here you will be dressed, given your post-operative prescription, and readied for discharge.  Our surgeons make every attempt to see you and/or your family prior to discharge, however scheduling may prevent them from leaving the operating room prior to your discharge.

 

Following Surgery

Pain Control

  • Your surgical team strives towards a common goal – no unnecessary pain following shoulder surgery. Recognizing this, your surgeon can help you prepare for expected post-operative pain. We take the following steps to help you through the first two post-operative weeks:
    • Awareness: Recognizing that pain following shoulder surgery is to be expected but can be managed will help decrease anxiety.
    • Non-Medication Measures: Preparing your home with a comfortable recliner chair will allow gravity to ‘hold out’ your joint and will also make sleeping more comfortable. Having access to ice-bags or a cryo-compressive device will help manage pain and swelling. It is important to note that while the nerve block is active, avoid direct contact of ice on your skin to avoid frost-bite (i.e. wrap an ice bag in a tea-towel).
    • Pre-operative Nerve Block: The block given to you before your operation should allow you to travel home and get comfortable before it wears off. It is difficult to predict how long the block will last, although most patients experience at least 8 hours of relief, with some as much as 48 hours. We recommend that once you get home you begin to take narcotic pain medication at the lowest dose based on the regimen detailed below – even if you are not currently in pain. As the block wears off, it is important to have some pain medications in your system to avoid ‘rebound pain’, where it becomes difficult to control discomfort after the block suddenly wears off.
      • Important Note: The longer the block lasts, the more important it is to occasionally check the position of your wrist and hand in your sling. Your wrist should be in a comfortable position, and your fingers should not be bent. As you cannot feel your hand while the block is in effect, it is important to avoid pressure areas that can develop over time.
    • Narcotic Medication: The use of some narcotic medication following surgery is necessary for the many of patients. Recognizing growing concerns over narcotic misuse in Ontario, we strive to provide patients with the medications necessary to get them through the first two weeks of surgery. Following this, we transition to non-narcotic medication as quickly as possible (see below). After considering medical allergy, patients are most frequently sent home with two separate short-acting pain medications. These medications may be staggered – so that a pain pill may be taken every two hours as necessary. For example: Pain Medication A is taken at time 0 and 4 hours, while Pain Medication B is taken at time 2 and 6 hours as required.
    • Non-Narcotic Medication: The following over the counter medications can be useful to have on hand to control mild to moderate pain following your surgery:
      • Acetaminophen (or Tylenol™): Can be taken in 650-1000mg doses every 6-8 hours as required. Adults can safely take upwards of 4000mg (or 4g) of acetaminophen a day. We consider this to be the best available non-narcotic medication available and recommend it as a first-line medication.
      • Anti-inflammatory Medications: Commonly sold as ibupriophen, Advil™ or Alleve™, these medications help control pain and work to decrease inflammation and swelling. They are recommended for short-term relief of pain alongside Acetaminophen, but should be avoided in patients with kidney damage or in those who have had prior bleeding from their stomach or intestines. There is also emerging evidence that these medications, if used daily over time, may have negative health consequences. For that reason, we recommended using these medications for only 3-5 days following surgery.
    • Recognize that pain is often the most intense when attempting to sleep or when waking up in the morning. In the evening, there is less stimulus to distract your body, thus the pain becomes more noticeable.  In the early morning, your body no longer has pain medications on-board, resulting in an element of rebound pain.  Recognizing the above will help decrease the surprise associated with this.

 General Post-operative Instructions (Weeks 0-6)

  • Sling: Please remain in your sling following surgery at all times for six weeks unless otherwise instructed by your surgeon. The only exception to this may be during your shower, during which we recommend sitting on a bath chair and holding your arm close to your body to protect it.
  • Showering: You may shower for the first time between two and five days following your surgery. It is important to let the soap and water run down your shoulder, and to avoid scrubbing your incision site (which can loosen sutures). After the shower, pat your shoulder dry, apply new bandages, and immediately go back into your sling.
  • Wound Care: Small incisions around the shoulder may be covered with a four-sided adhesive bandage (i.e. Band-Aid). Larger incisions can be covered with a ‘strip-dressing’, which functions as a longer adhesive bandage. Both are available at local drug stores.  Dressing should be changed every other day and as needed until the staples/sutures are removed.
  • Driving: For your safety and that of others, we explicitly request you do not drive while your shoulder is immobilized in a sling. In general, we recommend avoiding driving for a week or two longer than you were immobilized for, to allow you to be able to comfortably and safely operate a motor vehicle.
  • Physical Therapy: Physical therapy will either start post op week 2 or 6 depending on the procedure performed. In general, therapy starts once you are able to come out of the sling. Your surgeon will provide you with detailed instructions and a script to give to your therapist. It is important to remember the following:
    • Taking pain medication prior to physical therapy can allow you to progress through the exercises more comfortably, especially early in your recovery.
    • The sling is designed to immobilize your shoulder only. We strongly encourage you to perform finger, wrist, and elbow range of motion exercises as soon as you feel comfortable doing so. These exercises can be performed at home, even before you receive formal physical therapy. While performing these exercises, keep your elbow close to your body as you slide out of your sling will ensure your shoulder is protected while helping to ensure the other joints in your hand/wrist/elbow do not become stiff.
    • How quickly you recover depends on multiple factors: including the procedure performed and the extent of your initial condition. Try not to compare yourself to friends or loved ones who may have been operated on – instead look to your therapist and surgeon for guidance. Even people who have had both shoulders operated on will tell you – recovery commonly differs!
  • Unexpected Issues: During your post-operative course, it is important to know that your surgeon and their team are available to help. Your first point of contact should always be your surgeon’s administrative assistant, who is able to help with commonly encountered issues and can book you into see your surgeon as needed.
    • If serious or medically significant issues arise, you should present to the nearest emergency room for assessment. Unexplained chest pain, shortness of breath, fever, double-vision or prolonged and uncontrollable nausea is not normal and should prompt immediate assessment. It is important to note these issues to your surgeon when you see them next, as they may have not been made aware of any issues or changes in your health.

 Recovery and Return to Work (Weeks 2-12)

  • Recovery and return to work should be discussed prior to your surgical procedure with your surgeon. This allows you to make appropriate arrangements should a prolonged recovery be anticipated.
  • We strongly believe that participating in light, progressive daily tasks can be a form of therapy in itself. Once the sling comes off, we try to normalize your life as quickly as possible.
  • You should speak to your work about the possibility of light and/or progressive hours and duties upon your return.

Routine Post-Operative Follow-up

  • 2 Weeks (Fracture Clinic): Your surgeon will see you at Orillia Soldiers’ Memorial Hospital Fracture Clinic for wound care management and suture/staple removal. Please note that this is a high-volume clinic, please bring a book or tablet to provide entertainment should the wait be lengthy. We apologize for the wait in advance.
  • 5 Weeks (Office): In preparation for physical therapy to start at the 6 week mark, your surgeon will want to see you at 5 weeks to allow for adequate planning. Patients often feel the ‘itch’ to remove the sling prematurely, which allows us to advise against this.
  • 12 Weeks (Office): Goals are to prepare for the start of the strengthening phase of recovery, and to monitor progress with returning to work.
  • 6 Months (Office): Final Motion and strength testing. Please note that while people continue to improve following shoulder surgery for upwards of a year, this is often the final appointment as patients are often back to near full activities and full duties at work.

 

Unexpected Issues

This page cannot predict all issues that arise during your post-operative course. As each patient is different, discuss your unique concerns with the surgical team if applicable.

General inquiries regarding follow-up, pain-medication or antibiotic prescriptions, or work-forms can be directed to your surgeon’s office.

We recommend presenting to your local emergency room for the following issues: Chest pain, shortness of breath, persistent nausea/vomiting, concerns over infection, visual changes, loss of consciousness, seizure or seizure-like activity, or falls.