Dear Valued Patient,
We would like to personally thank you for entrusting your care to us. We have a passion for providing high quality, efficient, and effective care to meet your goals. We want you to have the confidence in knowing that providing you with a positive surgical experience is of the utmost importance to our team.
We believe communication is essential to providing quality care. To that end, we have prepared an extensive document encompassing what we think is important for you, as a patient, to know and understand prior to your surgery. Please read through this thoroughly as it will help you through your future surgical experience.
We strive to provide you with the best possible care and want you to know that we are committed to you both as a patient as well as a valuable member of our community. We have worked hard to optimize our practice in order to deliver an excellent patient experience. We are confident that we can deliver the results you need. If any questions should arise, please do not hesitate to contact our team.
Understanding Your Procedure
Arthroscopic surgery is a technique for performing shoulder surgery where the surgeon views the inside of your shoulder joint through a fiber optic “arthroscope”, or video camera. The arthroscopic device is approximately the length and diameter of a pencil. Using the arthroscope, we can visualize the joint surfaces, cartilage, bone, tendons, ligaments, nerves, and vessels. Once the problems causing your joint pain or dysfunction are identified, they can be repaired using specially designed instruments working through multiple small incisions approximately 1 centimeter in length. The use of arthroscopic techniques reduces scarring and lowers the risk of complications after surgery.
The more you know about your procedure, the better you will be able to face the challenges of your post-operative recovery. Do not hesitate to ask questions when you do not understand the information that we provide to you. My staff and I will instruct you in what you can expect before, during and after surgery. We will provide you with information about the process of being admitted to the outpatient surgery center, the type of anesthesia you will need, the amount of time required to perform your surgery and recover from your anesthesia, your post-operative pain management plan, and your post-operative rehabilitation. We will also contact you a day or two after your return home to make sure that your recovery is going well.
Optimizing Your Health for a Faster Recovery
Exercise before surgery
If it is not too uncomfortable, simple exercising such as walking, bicycle riding, or swimming will help you to recover more completely after your surgery. Stretching as tolerated will also help preserve your joint motion. Exercising that irritates your pain should be avoided.
Diet
Eat a healthy diet consisting of whole grains, quality protein, and a variety of fruits and vegetables. Take a daily multivitamin and with extra supplementation for calcium, iron, vitamin C and vitamin D3. We recommend supplementing starting at least 2 weeks prior to surgery and continuing at least 3 months after surgery.
Dental Work and other Medical Procedures
If you anticipate needing to have dental work, colonoscopies, or other minor surgical procedures, please schedule them more than one month prior to, or three months after your surgery.
Smoking
This is very important – Smoking anything with nicotine (cigarettes, vaping, cigar smoking) significantly increases your risk of complications during and after surgery, often leading to inferior outcomes. Wound, bone, and joint healing are all significantly reduced in smokers compared to non-smokers. Smokers have a greater likelihood of chest colds, pneumonia, strokes and heart problems after surgery compared to non-smokers. For all these reasons, I respectfully require that if you are a smoker, you need to stop smoking at least 2 weeks prior to your surgery and refrain from resuming this habit for at least a month afterward. Also, please understand that it is the nicotine in your system that interferes with the healing process, so do not use a “nicotine patch” or nicotine gum during your recovery from your surgery as this would have the same negative effect upon your healing as smoking. Please let us know if you need assistance with abstaining as there are multiple free programs that can help.
Controlled substances
If you use any “controlled substances” for any reason (prescription or non-prescription including marijuana or other THC containing products) please let us know far in advance of your surgery as they may complicate your recovery.
Surgical Checklist
Before Surgery
Obtain preoperative clearance (if applicable)
Schedule initial postoperative physical therapy appointment (if applicable)
Schedule initial postoperative clinic visit (usually 10-14 days after surgery)
Stop required medications
2 weeks before (narcotics and Aspirin, Non-Steroidal Anti-Inflammatories (NSAIDS) [Advil (Ibuprofen), Aleve (Naproxen), Voltaren (Diclofenac), Mobic (Meloxicam)], tobacco, herbal supplements)
1 week before (blood thinners [Plavix, Warfarin, Lovenox, etc.] per primary or cardiology doctor, recreational drugs)
24 hours before (alcohol)
Start or continue eating a healthy diet and supplementing with a daily multivitamin along with calcium, iron, vitamin C, and vitamin D3
Obtain prescribed recovery equipment (slings, crutches, braces, cold therapy, etc.)
Pick up postoperative medications from your pharmacy
Notify the office immediately if you develop any new illness
Day of Surgery
Do NOT eat or drink anything after midnight
Take your essential prescription medications only with small sip of water. If unsure, discuss with your primary doctor and/or our anesthesia team
Bring this preoperative packet
Bring a government-issued identification
Bring a credit card
Bring your medical insurance card
Bring your recovery equipment as above
Write a list of any new diagnoses, medications, or allergies since last visit
Wear comfortable clothing and shoes
Bring reading material (book, magazine, etc.) for down time
Do NOT bring: jewelry, piercings, valuable, contacts (wear glasses instead)
You must have a responsible adult must drive you home and stay with you overnight the first night (NO rideshare/taxi - NO exceptions)
Immediately After Surgery
Use our multimodal pain recommendations to reduce narcotics (see attached)
Perform incision care per attached instructions
Slowly resume your normal diet (simple healthy foods, limit spice/fat)
Prevent blood clots by following the attached instructions and medications
Perform postoperative exercises beginning immediately as instructed
Plan for friend/family assistance at home at least the night of surgery
Start physical therapy the first day after surgery (unless discussed otherwise)
General Postoperative Instructions
Use of Your Recovery Equipment
You will be given instructions specific to your surgical procedure describing your recovery plan and necessary equipment. If you are given a sling, brace, or other form of immobilization it is very important to wear it exactly as instructed to ensure appropriate healing or your surgery may become compromised. Please contact us if you are unsure of our recommendations.
Pain Management
Recovery from injury and surgery often involves a component of pain or discomfort. We utilize an evidence-based multimodal pain control regimen to provide you with the safest and fastest recovery while still optimizing comfort. During surgery, we also use careful dissection and tissue handling techniques to minimize surrounding injury. The experience of pain or discomfort is a combination of peripheral nerve signals and central processing. Having a positive mind-set and an optimistic attitude can greatly enhance your surgical experience and limit postoperative discomfort.
The following tips can help you reduce pain and discomfort while you recover:
Follow your postoperative protocol regarding immobilization and recovery equipment
Utilize cold therapy often during the first few weeks to reduce swelling and inflammation
Take pain medication as prescribed before pain becomes severe
Use Tylenol and anti-inflammatories (Aleve/Naproxen) to limit narcotic use
Only take narcotics if pain is severe, and taper off narcotics after the first few days
Communicate with our office if you consider pain to be excessive, uncontrolled despite adequate medication attempts, or significantly worsening
Plan ahead for refills as they will only be available Monday-Friday during clinic hours (8am-5pm). In general, we do NOT refill narcotic prescriptions.
Renewal of Pain Medication Prescriptions
In most cases, it is not possible to renew prescriptions for pain medication during a weekend. Prior to the beginning of a weekend, please check to ensure that you have enough pain medication to last you until the following Monday. If it appears you may not have a sufficient number of pain pills to last you through a weekend, you should call for a refill during office hours on Thursday, or at the latest, on Friday morning. Please do not wait until the last minute to call late on a Friday afternoon when the staff are getting ready to leave the office, and please respect my partners weekend time with their families by not calling the “on call physician” for pain medicine prescriptions on the weekend.
Other Medications
You may resume your regular prescription medications after surgery as directed by your prescribing physician, unless otherwise instructed. The one exception is blood thinning medication (Warfarin, Lovenox, Plavix) – timing for resuming these medications will be discussed in conjunction with your primary doctor before surgery.
You will be provided with a prescription for anti-nausea medication (Zofran) and a stool softener (Docusate/Senna) for use as needed for any side effects of the anesthesia or narcotic pain medication. These should only be taken as needed, and may not be needed at all. It is also important to stay hydrated and eat a healthy diet. Over-the-counter medications can be helpful as well; talk to your pharmacist for assistant with any over-the-counter medication requests.
For lower extremity surgery, you may also be given a blood thinner to help prevent blood clots (Aspirin or Lovenox). Please take this medication as prescribed for its full duration to protect yourself from developing deep vein clots that could travel to your lungs.
You will be given antibiotics before and during surgery. There will usually be no need for additional antibiotics once you go home unless specifically discussed.
You should return any unused medication to your prescription pharmacy for appropriate disposal.
Wound Management
Appropriate wound care is critical to prevent scarring and inflection in order to optimize your surgical outcome. In general, sterile surgical dressings should be left in place for 72 hours after surgery to allow for the incisional edges to heal and prevent bacterial contamination. Some bleeding is normal and may leak into the dressing. Bruising above or below the surgery (in some cases, the entire arm or leg) is also normal as well and will resolve with time. A combination of sutures, skin glue, and/or staples may be used to protect the incision and will be removed in the office. The following guidelines are important for safe skin healing:
Keep sterile dressings on for 72 hours after surgery (unless otherwise instructed)
You may loosen your outer wrap if needed within 72 hours for excessive pain or numbness
Reinforce any small leakage with additional dressings. If leakage is persistent or large, please contact our office
Keep the dressings clean and dry at all times
Do not place any ointments or creams over the incision at any time
Report any large areas of redness, persistent drainage, or skin opening to our office immediately
Ensure you can make your initial post-operative appointment for suture removal. If the appointment needs to be changed for urgent issues, please notify us immediately for a new appointment.
Sutures should not remain in place longer than 2-3 weeks.
Avoid sun exposure over incisions to limit scar development
Bathing
It is necessary to keep the incision dry for 72 hours after your surgery. During that time, it is best if you simply “sponge bathe.” Thereafter, you may get in a shower to bathe but do not scrub the incision, simply let the water run over the incision and then blot it dry with a clean towel once you are finished. Place a new dry dressing over the incision to protect it from the sun and abrasions. Do not submerge the incision under water until we give permission to do so.
Diet/Nutrition
A healthy diet with an assortment of whole grains, quality protein, fresh vegetables and fruits is important for good health and healing. After a surgery, your body will need additional nourishment as it heals your incisions and rebuilds your strength. Dietary supplementation with a daily multi-vitamin with additional calcium, iron, vitamin C and vitamin D3 is helpful to assist with healing - talk with your primary doctor or a pharmacist about supplementation. We recommend beginning two weeks before surgery and continuing for 3 months after surgery.
Sleeping
It is often difficult to sleep in bed for several weeks after a major surgery. The muscles around your arm or leg will be swollen and tender resulting in soreness and pain. At night, the discomfort from your surgery becomes more apparent and is aggravated when pressure is applied to these muscles either from lying partially on that side or simply from moving about in bed. Most patients with surgery find that they rest better if they sleep in a recliner chair, on a sofa or arrange their pillows in bed to position their trunk and shoulders to remove pressure from their operative extremity. When possible, we recommend placing the extremity on pillows while resting/sleeping to assist in reducing swelling.
Blood Clot Prevention
Formation of a blood clot in the deep veins (DVT) or lungs (PE) is a rare but documented risk of surgery. Certain individuals may be more at risk than others and it is important to let us know if you are aware of any personal or family history of DVT or PE in the past. A number of measures are taken during and after surgery to prevent these from forming, including leg compression devices and blood thinning medication as above. To help with prevention, it is important to perform the following exercises and elevate your operative extremity (above the level of your heart, if possible) during the early recovery from surgery.
Expedited Home Exercise Recovery
During your post-operative recovery, we and your physical therapist will teach you a series of exercises to regain your range of motion. Please do these as instructed three times a day. Do not add additional exercises unless asked to do so by us or your therapist. Do not use the surgical arm or leg to lift or move objects until instructed that it is safe to do so.
The following exercises should be performed the first day after surgery while awaiting formal physical therapy. Upper extremity exercises should be done for upper extremity surgery (shoulder, arm, elbow) while lower extremity exercises should be done for lower extremity surgery (hip, thigh, knee, leg, ankle).
Wrist and Hand Motion
Even if you are wearing a sling, it is important to maintain motion in your wrist and fingers to prevent stiffness. You should practice writing the alphabet with your hand and open and close your wrist ten times at least three times a day during your early recovery.
Elbow Motion (NOT for Biceps/Triceps surgery)
Gently remove your sling and use your other hand to support your operative arm. Let gravity slowly straighten your arm and use your other hand to bend your arm back up. Do not use the muscles on the operative side to help with any motion. Importantly, do NOT perform any elbow exercises if surgery was performed on the biceps or triceps!
Shoulder Motion
In certain cases, we may recommend early passive shoulder motion following surgery. This should only be done if specifically indicated by our team, otherwise do not perform these exercises. If instructed, gently remove your sling, place your non-operative arm on a table, and bend 90 degrees forward at your waist so your torso is parallel with the ground. Your operative arm should hang with gravity directly toward the floor. When you are comfortable, gently move your hand in a clockwise motion for 30 cycles and a counterclockwise motion for 30 cycles. Start with small circles and gradually progress to circles no larger than a frying pan.
Knee Motion
Place your leg on a flat surface with support and gently remove your brace. The following exercises will help restore early motion and improve joint health. Please perform these as tolerated.
Leg bridges: Sit down and position your heel on the edge of a chair or coffee table and remove anything supporting the back of your knee. Let gravity pull your knee towards the ground to stretch the back of your knee and improve your knee extension. Keep this in place for 1-2 minutes at a time for a total of 10 minutes and perform this exercise three times per day.
Heel slides: Lie down on your back on the floor or a flat surface. Use your hamstring muscles to pull your heel toward your hip, sliding your heel along the floor in order to flex your knee. Your goal should be to get to 90 degrees of knee flexion. Do not go beyond 90 degrees in the first two weeks after surgery unless otherwise instructed. Perform the slide 10 times and repeat this three times per day.
Quad sets: Fully support your leg on a flat surface. Flex your quadriceps muscle and hold for 10 seconds. Repeat this for a total of 10 repetitions and perform this exercise three times per day.
Ankle Pumps
Perform ankle pumps to help promote circulation in the legs. Lie on your back with both legs straight and pull your feet towards your head, then push your feet down away (as if pressing a gas pedal). Do 30 repetitions on each side every hour you are awake.
Rehabilitation
In most cases, physical therapy will be an integral aspect of your recovery. Safe guidance through the recovery process in an individualized step-wise manner is key for promoting an efficient, comprehensive recovery. Physical therapy appointments should be confirmed PRIOR TO SURGERY in order to begin therapy 24-48 hours postoperatively. We will provide recommendations for ideal therapy locations, so please work with our staff to help coordinate your appointments. Importantly, contact us directly if you experience any difficulties with obtaining a therapy appointment or any injuries during the recovery process.
Driving
It is not appropriate to consider operating a motor vehicle if you are taking narcotic medication as this is illegal and will cause a dangerous decrease in your alertness and slow your reaction time to traffic changes. Once you are no longer using narcotic pain medications during the daytime, it may be possible for you to drive using your nonsurgical hand or leg. Even if you are medically cleared to drive, that does not mean legally you are safe to drive. We do not have any equipment to test reaction time or driving safety, and therefore any return earlier than a full recovery is done at your own legal risk. Please discuss whether you are medically cleared for driving with us prior to attempting to do so as there may be other considerations requiring that you not drive.
Return to Work
Safely returning to work depends on a number of factors including the type of surgery, commuting requirements, and work demands. In general, patients may be able to work from home a few days after surgery. Desk work in the office may be accessible a week or two following surgery if travel assistance is available. Returning to functional work may take one or two months, while heavy labor may require six months or more for a full recovery.
Return to Sport
Similar to work, safe return to sport also depends on the type of surgery and functional sport demands. Generally, patients will work with their therapists to gradually increase sport-specific functional training in a safe environment prior to return. In certain cases, a functional sports assessment may be prescribed to ensure full rehabilitation to limit reinjury. It is important to discuss your ideal return timing with us so we can optimize your recovery to meet your goals.
Airport Security Issues
Small metallic devices implanted within your body at the time of your surgery (such as suture metal anchor devices or screws) are extremely unlikely to set off airport security screening devices. Prosthetic devices placed within your shoulder at the time of joint replacement are either partially or wholly comprised of metallic materials, which may set off airport security screening devices. If the walkthrough monitors are activated by your implants, the security agents may screen you with a wand. Under some circumstances of heightened security measures, airport security agents may also require that you show them your scar to confirm that you have indeed undergone this surgery, so you may want to wear a loose-fitting shirt or blouse that opens at the neck for this reason. We cannot predict airport security scrutiny, so we also advise having access to a copy of your medical records including your operative report, which is typically provided at your initial postoperative visit.
Notification Triggers
Open lines of communication are paramount in fostering a safe surgical recovery. Please do not hesitate to notify our office if you have any surgical concerns. We are here to help you and want to provide you with the best possible recovery experience. To that end, please notify us immediately if you experience any of the following symptoms:
Fever above 101.5 degrees Fahrenheit. (Keep in mind that a lower-grade fever (99-101 degrees) is often normal the first few days after surgery)
Large (over 1-2cm) or growing area of redness around the incision after dressing removal
Incision drainage that is persistent or soaking through your surgical dressing and reinforced dressing
Uncontrolled surgical pain despite attempts at oral medication pain control as prescribed and outlined above
New chest pain located in the sternum or upper chest region and/or radiating pains into your arms or upper jaw. of possible heart disease
Trouble breathing or shortness of breath. If you do not reach us immediately, we recommend going to an urgent care or emergency department for an evaluation of your lungs. Importantly, do not take any additional narcotic medication if you are experiencing shortness of breath without talking to a physician first.