Rotator cuff repair. Patient information

Transcription

1 Patient information Rotator cuff repair This leaflet has been designed to give you some more information about having a rotator cuff repair. Your surgeon believes you will benefit from this operation. The aim of the operation is to reduce your pain and so improve your function. Barts Health Therapies Department

2 What is the rotator cuff? The shoulder is a ball and socket joint and is made up of three bones; the humerus (arm bone), scapula (shoulder blade) and clavicle (collar bone). Your shoulder is the most mobile joint in your body and is therefore dependent on strong muscles to move and stabilise it. The most important muscles for this purpose are the rotator cuff muscles. The rotator cuff helps to rotate and raise the arm and prevents the shoulder from dislocating when the arm is raised. These tendons can be damaged through general wear and tear, or after an accident/fall. If one or more of these muscles are damaged, movement may become difficult and the shoulder becomes weak and painful. What is a rotator cuff repair? The operation aims to repair the damage to the torn muscles or tendons. Once you are under a general anaesthetic the torn muscles are repaired using sutures or suture anchors depending on the type of damage. Often a ligament is also released and a piece of bone may be shaved or cut away to allow more space for the repaired muscle to heal. The operation may be done arthroscopically (key hole surgery) or through an open incision. The type of approach used will be determined by the size and nature of the tear. What are the risks of having a rotator cuff repair? All operations involve an element of risk, these are very small but you need to be aware of them and can discuss them with your doctor at any time. The risks are: Complications relating to the anaesthetic Infection: These are usually superficial wound problems (rare; less than 1%). Stiffness and or pain around the shoulder Damage to nerves or blood vessels around the shoulder Failure of the repaired tendon to heal (approx 20%) On rare occasions the scar can become overgrown and with a type of dense fibrous tissue. This is termed as keloid or hypertrophic scarring. The cuff may be irreparable when examined by the surgeon in theatre. 2

3 Questions that we are often asked about the operation What sort of anaesthetic will be given to me? You will be given a general anaesthetic. General anaesthesia is drug-induced unconsciousness: an anaesthetist, who is a doctor with specialist training, always provides it. Unfortunately, general anaesthesia can cause side effects and complications. Side effects are common, but are usually short-lived: they include nausea, confusion and pain. Complications are very rare, but can cause lasting injury: they can include paralysis and death. The risks of anaesthesia and surgery are lower for those who are undergoing minor surgery, and who are young, fit, active and well. You will be given an opportunity to discuss anaesthetic options and risks with your anaesthetist before your surgery. If you are worried about any of these risks, please speak to your Consultant or a member of their team. Often the general anaesthetic may be combined with a regional anaesthetic. This will be discussed with you pre-operatively, and involves the injection of local anaesthetic around the nerves at the base of the neck that supply the shoulder and arm. Depending on the type of local anaesthetic used, the effects may last hours or sometimes even days. The advantage of using this technique is that you are likely to be far more comfortable immediately post operatively and therefore will require less strong pain killers and are less likely to feel sick following the surgery. For this reason patients recover usually far quicker immediately post operatively. There is a risk of nerve injury or sensitisation following this procedure, but it is very rare. Getting ready for your operation The staff will ask routine questions about your health, the medicine you take at the moment and any allergies you may have. You will be given instructions on eating and drinking. You will be able to discuss the operation with a doctor. You will be asked to sign a consent form to say that you understand the procedure, and what the operation involves. What happens on the day of your operation? You will come into hospital on the day of your operation. Please make sure you contact the ward before you leave home to check bed availability. Please leave all cash and valuables at home. The Trust does not accept responsibility for items not handed in for safekeeping. There is a very small lockable cupboard by your bedside which will be used to store your medication and small amounts of petty cash. It cannot accommodate large items. You will be asked to remove jewellery. Rings worn on the hand on the operated side must be removed. Please leave body piercings at home. Acrylic nails and nail polish will also need to be removed. If you are on regular medication, you will be told to take this if necessary. If you already have a prescription for anticoagulants or medication that thins 3

4 your blood, such as warfarin/ aspirin/ clopidogrel, you will have instructions on when to stop the medication. A bracelet with your personal details will be attached to your wrist. You may be prescribed some medication to take before your operation by the anaesthetist. A member of the nursing staff will give this to you. You will be given a gown to wear for your operation. A nurse and porter will accompany you to the operating theatre. Your dentures, glasses or hearing aid can stay with you on your journey to the operating theatre. When you arrive in the waiting area, a theatre nurse will check your details with you. The ward nurse will then leave you and you will then be taken to the anaesthetic room. What should I expect after the operation? After your operation you will be kept in the theatre recovery room before being transferred to the ward. A nurse will check your pulse, blood pressure, and breathing rate regularly. It is important that if you feel any pain you must tell the nursing staff, who can give you painkillers to help. The first time you get out of bed, please make sure you ask a nurse to be with you. This is in case you feel dizzy. When will I go home? Usually you will be discharged home the same day as your surgery. Occasionally you may be kept in hospital overnight but this is unusual. Remember that you have just had an operation. It is normal to feel more tired than usual for a few days after having an operation. If you have had a regional nerve block, you are likely to feel little pain post operatively. Sometimes the block can be very dense and also lead to weakness in the muscles of the arm and hand and well as numbness. Do not worry, the function does return when the anaesthetic wears off. It is important for you to be particularly careful with your arm and protect it in the sling initially as during this period it will be numb. It is also very important you start taking your pain-killers regularly straight away, despite having little of no pain. Your shoulder is likely to be uncomfortable in the first few days post-surgery. This is normal. You may not feel there is a significant improvement in your pre-operative pain until a few weeks after surgery. Discharge information Will I be in pain? It is normal to feel some pain following your operation. You will be given some painkillers and/or anti-inflammatory medication to take in the days following the 4

5 operation. It is vital to begin the tablets prescribed by the surgeon immediately after the operation even if you are pain free because of a very effective nerve block. It is important that you have adequate pain relief for when the block eventually wears off. Using ice on your shoulder can be helpful in reducing pain. Wrap a bag of crushed ice, or frozen peas in a damp towel. Protect your dressings from getting wet with a layer of cling film, or a plastic bag, before applying the ice pack for minutes at a time. Posture can make a big difference to your pain after surgery. Avoid hitching your shoulder or holding it in an elevated position. Keeping your arm parallel to the body by supporting it with a pillow can make a big difference in your pain (See the section on getting back to normal below for a diagram). What do I do about the wound? You will not have any stitches, only small sticking plaster strips over two or three small wounds. Keep the wounds dry until they are healed, which is normally within 14 days. You must keep them covered when showering or bathing for the first two weeks. Your shoulder is filled with water during the operation and this often will make your shoulder look very swollen initially. The wounds sometimes allow some of this fluid to escape which will be blood stained. Do not be alarmed. If your dressings become soaked following discharge, either attend your GP practice to change them or attend our fracture clinic. How long do I need to wear the sling? Your arm is supported in a sling straight after your operation to protect the repair. It is essential that you wear the sling day and night for six weeks (your physiotherapist will advise you). The amount of time will depend on the size of the rotator cuff tear. This will be explained to you after your surgery. You can remove the sling to carry out your exercises and for washing and dressing only. Are there things that I should avoid? Yes, it is very important to protect the tendon repair. You will be advised to wear a sling for approximately six weeks. Do not lift your operated arm without assistance until it is allowed by the surgeon or physiotherapist. Do not use the un-operated arm for any heavy manual work whilst the operated arm is in the sling. Do I need to do exercises? Yes (see at the end of this leaflet) you will be shown exercises by the physiotherapist and you will need to continue with the exercises once you go home. They aim to stop your shoulder, elbow and wrist getting stiff. Passive shoulder movement is important to avoid stiffness but at the same time avoid putting any tension of stress on the muscles and tendons that have been repaired. 5

6 How long will it take me to recover? It can take up to 12 weeks after surgery for your pain to start to improve. During the first six weeks the arm is resting in the sling the pain may be minimal. Once your exercises are progressed at six weeks you may notice a slight increase in your pain symptoms. Usually there are small improvements in range of movement and pain in the first six twelve weeks after the operation. Unfortunately progress can seem slow as tendons take a long time to heal. Full recovery is likely to take 9-12 months. What is the long-term prognosis? You will continue to improve up to a year following the operation, but from six months these improvements are usually much slower. Everybody is individual and makes progress at slightly different rates, but overall more than 85% of patients get a satisfactory result in the first six months. Getting back to normal how you can help yourself to recover Sleeping can be uncomfortable if you try and lie on your operated arm. We would recommend that initially you lie on your back or on the opposite side. If you lie on your back support the operated arm with a folded pillow under your lower arm. Make sure that your elbow is parallel to your body and avoid it falling backwards (see picture on right). In the first few weeks after surgery you will find it helps to support your arm when you sit as well. Put pillows behind you shoulder and elbow to prevent the arm from falling behind your trunk (see picture on left). These techniques have two benefits. 1. Protects the repair. 2. Reduces pain. Returning to activities When can I drive? You should not drive until you have discussed your progress with your consultant / physiotherapist which will not be until at least six weeks following your operation. You must be able to comfortably control your vehicle and perform emergency manoeuvres. When can I return to work? The amount of time you have off work depends on your job. If you have a manual job, or one that involves lifting or overhead activities, you will not be able to do this for six to nine months. Please discuss this with your consultant or physiotherapist. 6

7 When can I return to sports and leisure activities? The timescale for which you can go back to any previous sport or activity will depend on your movement and strength and the particular activity you have in mind. Please discuss returning to any activity or sport with your consultant or physiotherapist. Physiotherapy appointments - how often will I have to attend? You will be referred for outpatient physiotherapy and until you have that appointment you are expected to start the exercises on this sheet as soon as possible after the surgery. You have an important part to play in your own recovery and are expected to follow your home exercise programme as instructed. Further appointments when will you back to see the doctor? You will be seen in outpatient clinic approximately two weeks after your surgery. This appointment will be made and given to you before you are discharged from hospital. Further clinic appointments are made after this as necessary. What are the alternatives for treatments are available? You are having this surgery because other treatment options have been unsuccessful or are likely to be unsuccessful. A complete tear in a shoulder tendon is unlikely to heal without surgery and you may be left with considerable weakness in the arm. However, there is a time scale to surgery. The longer one has a torn tendon, the more likely the muscle behind it will weaken and this reduces the potential for healing and function. It is important to understand that this surgery does involve a significant amount of time and rehabilitation which naturally must have your complete involvement to achieve the best result. The benefits of surgery may take up to nine months to be reached although you should be feeling a lot better by the three month point. 7

8 Important things to remember following your Rotator cuff repair 1. Continue to wear your sling day and night as requested by your consultant. 2. Do not lift your operated arm without assistance until instructed. 3. Do not use the un-operated arm for any heavy manual work whilst the operated arm is in the sling. These are important to protect the repair of the tendon/s. Notes 8

9 Exercises Day one after the operation: Use painkillers and/or ice packs to reduce the pain before you exercise, if necessary. Do short, frequent sessions (e.g. five to10 minutes, five or six times a day) rather than one long session. It is normal for you to feel aching, discomfort or stretching sensations when doing these exercises. However, intense and lasting pain (e.g. for more than 30 minutes) is an indication to change the exercise by doing it less forcefully or often. When you are not doing your exercises ensure your shoulder is supported by pillows or your sling as described earlier in this leaflet, to assist with pain relief. Ensure you keep your neck, elbow, wrist and hand moving after the operation. These exercises can be started straight after the operation: 1. It is important to set the shoulder blades in a good position before commencing with these exercises. In order to do this you need to sit up straight with elbows by your sides, gently lift the tips of your shoulders very slowly upwards about two centimetres. The base of your shoulder blades will lift up and outwards very slightly. Hold for five seconds Repeat 10 times In lying position 2. Lying or sitting. Slowly take your operated arm up towards the line of your shoulder (90 degrees) using your un-operated arm. Take it no higher than shown in the picture. Repeat 10 times 9

10 3. Lying on your back. Hold your elbow bent at a right angle close to your body while it rests on your stomach. Hold onto your wrist with the unoperated hand. Try to move your hand outwards to in line with your shoulder. Do not go past the movement shown in the picture. Repeat 10 times In sitting position 4. While sitting: a) Start with your upper arms close to your sides and elbows at right angles. Rest your palm on a table on a piece of cloth (a tea towel) or a plastic bag that will slide easily along the table. b) Slowly slide your hand forward across the table reaching out as far as you feel comfortable Repeat 10 times In standing position 5. Take your arm out of the sling and straighten your elbow. Movement should only occur at the elbow not the shoulder. Hold for 10 seconds Repeat 10 times Day 14 + You will begin a course of physiotherapy to check your recovery after surgery and your exercise regime will start to include strengthening exercises. 10

11 Where can I get more information? The telephone numbers and contacts below are available for you to contact a physiotherapist. You will have the opportunity to ask your Orthopaedic Surgeon questions about the operation during your consultation or you can also contact them via their secretary through the Barts Health switchboard. - this is a very good site that has a lot of information written by Orthopaedic Surgeons specialising in the Upper Limb. Patient Advice and Liaison Service (PALS) If you need general information or advice about Trust services, please contact the Patient Advice and Liaison Service (PALS) on or visit Alternatively please contact staff who are providing your care if you require clinical advice. Your health records To enable us to improve the quality of the care that we provide, your health records are kept by the Trust and may be used for teaching, training, audit and research. Further information on how the Trust uses your information can be found on our website at Contact information Barts Health Therapies Department The Royal London Hospital Telephone No: bhnt.bartshealthphysio@nhs.net Mile End Hospital Telephone No: bhnt.bartshealthphysio@nhs.net Authors: Jenny Harper, extended scope physiotherapist Mr Ali Noorani and Mr Livio Di Mascio, consultants in trauma and orthopaedic surgery. Large print and other languages For this leaflet in large print, please ring or For help interpreting this leaflet in other languages, please ring Reference: BH/PIN/180 Publication date: January 2014 All our patient information leaflets are reviewed every three years. Barts Health NHS Trust Switchboard: