Surgical Treatment of Rotator Cuff Impingement
and Acromio-clavicular Joint Arthritis
Why this letter?
I think most people find going to see the doctor a difficult and emotional experience that I think is more stressful when potential surgery is a consideration. While many of the things we discussed are simple, you may quickly forget the details. Hopefully, this letter will serve to remind you of our meeting and answer any questions that arise.
What is wrong with your shoulder?
Your shoulder pain arises from a problem
in the biceps tendon and the rotator cuff tendons. A tendon is the thick, cord-like structure that allows muscles to connect to bones. In the shoulder 4 of these tendons are called the rotator cuff. The biceps and rotator cuff tendons have to pass between two bones, the acromion and the humerus. The space is small and normally the tendons just pass through as the arm is raised and rotated. With repeated overuse, a single injury or even just the wear and tear of age, the tendons increase in size and get pinched or impinge between the two bones.
Another common condition is arthritis of the acromio-clavicular joint. The cartilage between the acromion (the bone on top of your shoulder) and the clavicle (collar bone) is damaged. The two bone ends rub against each other and produce pain.
What happens if surgery is not performed?
Based on current medical knowledge the problem will likely continue. With time the pain may increase in severity. The possibility exists that the pressure on the tendon will cause further tendon damage such as partial tearing or even a complete tear in the tendon. Of course, the problem
may remain static or even improve with time, but again, this does not seem likely to occur in your case.
What is the purpose of the surgery?
During surgery I inspect the entire shoulder joint as well as the ligaments and tendons. I use small, motorized instruments to remove any inflamed or scarred tissue contributing to the problem. I then use a special instrument to repair the torn or inflammed biceps tendon (usually with a plastic screw) and remove that portion of the acromion bone and-or the clavicle that is causing pressure on the tendons. We have found that bone and scar tissue removal increases the space through which the tendons pass and allows recovery in 85-90% of patients.
What is the surgery like?
This surgery is done using arthroscopic technique. Instead of a large incision I use 2-3 Surgical Treatment of Rotator Cuff Impingement and Acromio-clavicular Joint Arthritis small (about 1/2”) incisions. Through 1 incision I insert the arthroscope which lets me look inside your shoulder. The other incisions are used to insert special instruments that allow the removal of scar tissue and bone spurs. When you arrive at Texas Orthopedic Hospital a nurse will have you sign the Operative Permit. The name of the operation I will be doing is “Operative Arthroscopy, shoulder: Biceps tenodesis and Subacromial Decompression.”
If you need an acromio-clavicular joint resection, this will be added to the permit.
Are any other options available?
While I believe surgery is the best course of action, other treatments are available. These vary from no treatment, just living with the condition, to physical therapy exercises, medication or injections. While any of these treatment options may be successful in your situation, in my experience they will not work reliably. We can arrange for any or all of these options if you desire.
What I recommend.
In view of your description of your problem, my physical examination and review of the x-rays I believe that surgery is medically indicated on your shoulder. The indications for surgery are persistent pain interfering with your activities of daily living, work and/or sports.
What kind of anesthesia is used?
Since this type of surgery cannot be done with local anesthesia we use general anesthesia which allows us to work deep inside your shoulder. Before you go to sleep, the anesthesiologist will give you an injection. A type of novocaine that lasts 12-18 hours is injected around the nerve that goes to the shoulder. This will help decrease the pain after the surgery.
What will you feel when you wake up?
Following surgery you will awaken in the recovery room with your arm in a sling. After surgery
to support your arm we use a special sling and an attached ice pack to control the pain and swelling. Nothing can eliminate the pain completely but medication, sling and the ice pack will control it so that you will be as comfortable as possible.
How long will you stay in the hospital?
Patients enter the hospital in the morning, have the surgery and go home the same day. This is called Outpatient surgery.
What about complications?
Shoulder surgery is a complex and delicate process designed to repair damaged structures deep within the human body. Complications
can occur. Fortunately these are rare. The most common complication involves injury to nerves around the shoulder. These usually
go away in 2 days to 6 weeks. This occurs in less than 1% of patients. Permanent injury that results in diminished use, function or feeling in the extremity can occur but is exceedingly rare. Infection can occur, less than 1%, and may require oral antibiotics, antibiotics by injection and rarely surgery.
How successful is the surgery?
This type of surgery is successful about 85-90% of the time. No shoulder operation is 100% successful in every individual but the procedures we perform are reliable and will help restore the potential function in your shoulder. The operation is most successful at relieving pain. What is harder to accomplish is the return to vigorous overhead use of the arm in work and/or sports. Whether you can return to your previous level is an individual matter and depends on the damage to your shoulder, how well it heals, how well you rehabilitate and how strenuous is your desired level of work or sports. Because of the many variables involved I can make no guarantees
other than to assure you I will deliver the very best medical care possible.
When can you return to routine activities?
You will wear the sling for 3 weeks in order to allow the biceps tendon repair to heal. Remove your sling for bathing, dressing and shoulder exercise. Do not lift or carry anything with your operated arm until I see you in the office. You will be able to use your fingers and wrist immediately after surgery. You may shower or bathe with regular soap and water 24 hours after surgery. You may walk outdoors, write, cook (1 hand), and drive a car (automatic shift) the next day. You may remove your sling to move the arm gently. Keep the elbow to your side. Try to use the ice pack for 1 hour, 4 times per day while you are at home. When you are outside be sure to wear your sling.
When can you return to work?
For most sedentary jobs I recommend 2-3 days off work. When you return to work your arm will be sore but you should be able to manage as long as you wear your sling and do no lifting, pushing, pulling or carrying. You will generally need 3 months before recovery is complete and return to heavy lifting or prolonged overhead use may require 6 months. There are no fixed rules for return to work. What I have described above are reasonable guidelines that I hope will help you and your employer ease your return to the workplace.
How is the shoulder rehabilitated?
Fortunately, you can usually perform the necessary exercises by yourself at home. I will decide when the different types and levels of therapy are appropriate and then I will show you what to do and give you the necessary materials. I like to have patients start aerobic exercises as soon as possible. You may enjoy walking, and stationary bicycle riding as soon as you wish after your surgery. Jogging, Stairmaster and regular bicycle riding can start after your first office visit 3 weeks after surgery. Swimming, running, and tennis groundstrokes start 6 weeks after surgery. Return to overhead throwing, tennis strokes and contact sports can require 3-6 months of rehabilitation. Full return to competitive, overhead sports may require 6-12 full months. My personal feeling is that the goal of this operation is to eliminate or diminish pain and allow you to comfortably perform normal activities of daily living.
When do you return to the doctor’s office?
Your first office visit is 3 weeks after surgery so that I can examine the surgical incision. I will give you additional instructions for exercises and discuss your allowed activity level. Six weeks after surgery more vigorous use of the shoulder will be allowed. Office visits then occur 3 and 6 months after your surgery if they are necessary. At each visit I will evaluate your progress and instruct you in specific exercises designed to maximize motion, strength and coordination. The successful outcome of your surgery is dependent on a constant process of evaluation that occurs at the office visit. This is not the type of surgery that I can just perform and achieve a success without your help. A successful result requires that patient, surgeon and therapist work together. Regular office visits are a critical part of your care.
What about pain medicine?
You will be given a prescription for pain medicine when you leave the hospital. Have this filled at your local pharmacy. Please take this as directed. That means that you may take the pills every 3-4 hours as needed. Take the medicine with food in your stomach. Taking the medicine on an empty study can cause nausea. You do not have to take the pills if simple rest, arm repositioning or the Cryo Cuff ice pack controls the pain. When you need more medication, contact your pharmacy and they will call the office so that we may refill the prescription. We cannot do this after 5:00 PM, as no one will be in this office. We cannot refill narcotic medication on weekends. One of my colleagues at the Fondren Orthopedic Group is available 24 hours a day, 7 days a week but we ask that you restrict after hours and weekend call to emergencies only and let us handle less urgent problems during the week.
How much does the surgery cost?
Since you (or your employer) have chosen an insurance carrier with particular benefits and because insurance coverage is a complicated business with no fixed rules, please check with your insurance carrier in regard to the specifics of your proposed shoulder surgery. Also note that the hospital bill is not something that I can control, so please direct any questions regarding
the specifics of the hospital, x-ray, laboratory and anesthesia bill to the hospital billing office. The insurance code for biceps tenodesis surgery is 29828. The insurance code for subacromial decompression surgery is 29826. 29824 is the insurance code for acromio-clavicular joint resection.
Why all the questions about your health?
Although the operation involves your shoulder, your entire body will react to the anesthesia
and surgery. Your general medical condition is obviously important. If you are younger than 50 and in good health, routine laboratory test will be performed the morning of surgery. You will need to see an anesthesiologist before surgery. If you have any medical problems, the anesthesiologist will inform us and one of the Internal Medicine doctors with whom we work with will contact you or your regular doctor prior to surgery. I feel this will provide you with the best medical care.
What if you have more questions?
We encourage you to return to the office for a further discussion at any time. There is no charge for pre-operative conferences.
How do you schedule surgery?
Contact Evelyn by phone at (713) 799-2300. I perform surgery on Tuesday and Thursday.